Insurance denial for a bi-lateral Mastectomy

Prophylactic Mastectomy
Greg - Self insured carriers may certainly be more restrictive than traditional group health carriers. I don't have statistics but am one of those who had a prohylactic mastectomy on the other side even though my oncologist said that I was eligible for just a lumpectomy on the side with cancer. My health insurance carrier paid for both sides (although my surgeon had me sign a waiver in case they didn't saying that I would pay). If your wife plans to appeal, you may want to talk with her oncologidt and surgeon to see if they will write a letter to support her decision. You may also want to go onto the websites of some of the major group health carriers (CIGNA, Aetna, United HealthCare, your state BCBS, and Anthem BCBS). Most of these carriers allow public access to their utilization review/medical policies and if you can show that group health carriers would typically pay, it may help persuade her self-insured carrier to cover it if that is her choice. Good luck!

Chris

Aortus said:

Sorry to hear...
Greg,

My beloved Moopster had a mastectomy in November 2008, six days after being diagnosed with what turned out to be stage IIIa "triple (what a crappy term) negative" BC. She is now a year and a half out and strongly considering a prophylactic mastectomy on the other side. I'm 100% in favor of her decision, and her oncologists are supportive too.

If and when that time comes, I don't know if Moopy's insurance will pre-approve the surgery, but her docs seem to think that the "triple negative" is a strong argument in favor. I do know that the insurance company better go ahead and go along with Moopy's decision because she will make their lives an absolute hell if they don't. I hired HR Block to do our taxes this spring because I was sure we had a mountain of medical deductions. As it turned out, Moopster's insurance covered more than 99% of her bills. No itemized deduction... no complaints, either!

Best to you both and God Bless,
Joe (Aortus)

ins cvg for prophylactic
My initial biopsy was IDC in one breast. I had previous radiation treatments 20 years ago for Hodgkins Lymphoma, therefore I elected a double mastectomy. My doctors pre auth it by saying "high possibility" for BC at a later date. Ended up the "good breast" had LCIS and I would have had another BC diagnosis down the road if I didn't do both. It was easier for me to get approval considering I was 22 times more likely than the avg woman to get BC. I would hope all ins covers prophylactics, reducing stress realted illness, mammo, ultrasound and biopsy costs down the road. Seems like a win-win for both consumer and insurer!