Reduction surgery denied

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keep_on_going
keep_on_going Member Posts: 21
edited March 2014 in Breast Cancer #1
6 years ago I had a wide excision biopsy (lumpectomy) followed by axillary node dissection. The surgery has left me with 1 C-D cup that's a little scarred but perky & 1 DDD plus. I was thinking about reduction surgery on my non CA breast. I would like them to match somewhat & I am tired of wearing a prosthesis. I was told by my insurance company that they would not cover the surgery. If I had had a mastectomy, they would pay for reconstruction. But they would not pay to make me equal in appearance.
Has anyone else had this problem? Any suggestions or resources out there? I find it hard to believe that since I didn't have it all taken off,I am being denied a surgical procedure that would restore my equilibrium. Breast sparing surgery comes with it's own set of problems

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  • webbwife50
    webbwife50 Member Posts: 394
    #2
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    Not right!
    That is just not right, and you must surely be upset! I can't offer advice, but I would keep looking into it. Did you ask your insurance directly? Maybe going through a physician referel would change the decision, I'd try telling em I want the affected breast enhanced, just to make a point! I'm sure others here will have better comments. Hugs..alison
  • webbwife50
    webbwife50 Member Posts: 394
    #3
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    double post
    I don't even think that is legal!
  • patti anne
    patti anne Member Posts: 101
    #4
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    not right...fight it
    I don't have any laws to quote, but when my insurance co. denied the removal of my right breast...I had only had the left removed and when I went to do reconstruction, I wanted to remove the remaining breast and reconstruct both sides. Anyway...insurance denied the removal and my plastic surgeon told me that legally, they had to pay to make my breasts symmetrical. I would definitely look into it further.

    That really ticks me off. Sorry.

    Patti
    (I ended up reconstructing the left side and when I did the nipple surgery, the PS lifted my right breast)
  • VickiSam
    VickiSam Member Posts: 9,079 Member
    #5
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    patti anne said:

    not right...fight it
    I don't have any laws to quote, but when my insurance co. denied the removal of my right breast...I had only had the left removed and when I went to do reconstruction, I wanted to remove the remaining breast and reconstruct both sides. Anyway...insurance denied the removal and my plastic surgeon told me that legally, they had to pay to make my breasts symmetrical. I would definitely look into it further.

    That really ticks me off. Sorry.

    Patti
    (I ended up reconstructing the left side and when I did the nipple surgery, the PS lifted my right breast)

    Laws forbid this type of bias ... Each and every
    breast cancer WARRIOR has the 'right' to have her breasts .. symmetrical, regardless of time.

    Take it up with your insurance review board, and HR department.

    Good Luck ..

    Strength and Courage:-)


    ♥.•´¸.•~♥♥♥~•.¸♩♫♬♪♥.•Vicki Sam´¸.•~♥♥♥~•.¸
  • Scotch Freckles
    Scotch Freckles Member Posts: 273 Member
    #6
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    I have the same problem. I spoke with my insurance carrier and here was the help desks recommendation. Go ahead see a surgeon. Should surgeon recommend corrective surgery for BC mess and there is considerable problems with DDD (Not Diners, Driving, & Dives either), pain in shoulders, back, etc. and he can medically justify reduction, go for it. I am still considering just the look see appointment. Not sure I can go through the reduction process.
  • pinkapples
    pinkapples Member Posts: 54 Member
    #7
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    As if
    There's not enough to already deal with! Bummer :(

    I had the same issue at first and was told the same thing. (I was a DD) However, my surgeon refused to accept the insurance answer and found a way around it by saying she would reduce my remaining breast for "health reasons". A couple surprises changed everything quickly and I had a bi-lat mastectomy so this ended up being all in vain! But...
    There are ways around it. Work with your Dr, or nurse, or patient advocate, your insurance rep, somewhere you will find someone creative enough with thier wording to get you the peace of mind you deserve> Heck, You have earned it!

    Stay stong sister and dont take no for an answer :)
  • CypressCynthia
    CypressCynthia Member Posts: 4,014 Member
    #8
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    First step I would take is
    First step I would take is to appeal their denial in writing. Do not telephone.
  • Lighthouse_7
    Lighthouse_7 Member Posts: 1,566 Member
    #9
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    CypressCynthia said:

    First step I would take is
    First step I would take is to appeal their denial in writing. Do not telephone.

    I was told by my surgeon
    I was told by my surgeon that insurance WOULD cover that because I have the same problem that you do. Although my good breast is only a D. It causes so many problems for the uneven weight issue! I haven't done it yet, because I'm taking a break from hospitals for a while, but I always was assured that I could do it.
    I think you should fight it. My surgeon said that in the case of breast cancer, it is covered.
    Good Luck!
  • MyTurnNow
    MyTurnNow Member Posts: 2,686 Member
    #10
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    Yes you can!
    I agree with VickiSam and like she stated there are now laws that protect you. Symmetry after breast cancer is covered by insurance. Like Vicki said, go back to your insurance company to repeal this. It may also help to get your surgeon involved. Good luck. Let us know how it all comes out.
  • keep_on_going
    keep_on_going Member Posts: 21
    #11
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    Additional News
    I took everyone's advice & persued it further. The case manager said to make an appointment with the plastic surgeon. He would know how to file the necessary papers with the Insurance Company. Learned my lesson. Always keep going & don't take no for an answer. I hope this post helps someone else.
    Cathy
  • keep_on_going
    keep_on_going Member Posts: 21
    #12
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    Scotch Freckles said:

    I have the same problem. I spoke with my insurance carrier and here was the help desks recommendation. Go ahead see a surgeon. Should surgeon recommend corrective surgery for BC mess and there is considerable problems with DDD (Not Diners, Driving, & Dives either), pain in shoulders, back, etc. and he can medically justify reduction, go for it. I am still considering just the look see appointment. Not sure I can go through the reduction process.

    it is acary
    Every time I have thought about reduction surgery something else comes up. I think I'm ready to go through with it now. You'll know if the time is right for you. Good luck!
  • roseann4
    roseann4 Member Posts: 992 Member
    #13
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    keep_on_going said:

    Additional News
    I took everyone's advice & persued it further. The case manager said to make an appointment with the plastic surgeon. He would know how to file the necessary papers with the Insurance Company. Learned my lesson. Always keep going & don't take no for an answer. I hope this post helps someone else.
    Cathy

    I would contest that decision.
    I was told differently by my surgeon. I decided against the surgery but my insurance would have covered it. With a big difference, it could lead to back issues in the future. I would fight this. Have your doctor write a letter to the insurance carrier explaining why the surgery is necessary in your case. The Susan B. Kolman foundation fought for our right to reconstructive surgery and won. I would contact them as well to confirm your right. They tried to get out of paying for my OncoTypeDX test saying it was out of network. We fought and they paid for most of it.

    Roseann
  • Kylez
    Kylez Member Posts: 3,761 Member
    #14
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    keep_on_going said:

    Additional News
    I took everyone's advice & persued it further. The case manager said to make an appointment with the plastic surgeon. He would know how to file the necessary papers with the Insurance Company. Learned my lesson. Always keep going & don't take no for an answer. I hope this post helps someone else.
    Cathy

    I hope your insurance will
    I hope your insurance will approve it. It is a shame that you have to go through this, but, don't give up.

    Good luck!

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