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11-04-2007, 09:58 PM
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#1
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Senior Member
Join Date: Feb 2006
Posts: 1,014
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Insurance and reconstruction..how long
This might sound like a stupid issue considering all that we've gone through. But how long will insurance pay for breast cosmetic surgery after initial surgery. I had a lumpectomy in my right breast and all and all it looks fine, scars are very small. It's just now about 2 sizes smaller than my left breast. Most people wouldn't even notice it and it's not that huge of a difference, but it does effect my bra and it bothers me. When I look down at myself I just see this big left boob and a smaller right one. I would really like to have the left one reduced because I've never been a fan of big breasts. Would insurance even consider paying for something like this. I know a lot of people are slightly lopsided naturally but I wasn't. I'm not overly vain, I'd just like my boobs to match like before.. sherryg
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Sherry
Diagnosed: December , 2005 at age 44
13+ positive lymph nodes
Stage IV , Her2+, 2 small mets to lungsChemo Started: Jan, 2006
4 months Taxotere, Xeloda, Hercepin
NED since April 2006!!
36 Rads to follow with weekly Herceptin indefinately
8 years NED now
Scans every year
Life is not about avoiding the thunderstorms, it's about learning to dance in the rain!
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11-05-2007, 12:06 AM
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#2
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Senior Member
Join Date: Feb 2006
Location: Southern, CA
Posts: 2,511
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Sherri, I am pretty sure that there was a law passed back in 97 or 98 that says insurance companies have to pay for reconstruction. I don't believe there is any time limit on that either. (I suppose there could be difference's in some states...but I doubt it.) I really do believe they have to cover you. Someone correct me if I'm wrong.
Chelee
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DX: 12-20-05 - Stage IIIA, Her2/Neu, 3+++,Er & Pr weakly positive, 5 of 16 pos nodes.
Rt. MRM on 1-3-06 -- No Rads due to compromised lungs.
Chemo started 2-7-06 -- TCH - - Finished 6-12-06
Finished yr of wkly herceptin 3-19-07
3-15-07 Lt side prophylactic simple mastectomy. -- Ooph 4-05-07
9-21-09 PET/CT "Recurrence" to Rt. axllia, Rt. femur, ilium. Possible Sacrum & liver? Now stage IV.
9-28-09 Loading dose of Herceptin & started Zometa
9-29-09 Power Port Placement
10-24-09 Mass 6.4 x 4.7 cm on Rt. femur head.
11-19-09 RT. Femur surgery - Rod placed
12-7-09 Navelbine added to Herceptin/Zometa.
3-23-10 Ten days of rads to RT femur. Completed.
4-05-10 Quit Navelbine--Herceptin/Zometa alone.
5-4-10 Appt. with Dr. Slamon to see what is next? Waiting on FISH results from femur biopsy.
Results to FISH was unsuccessful--this happens less then 2% of the time.
7-7-10 Recurrence to RT axilla again. Back to UCLA for options.
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11-05-2007, 12:45 AM
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#3
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Senior Member
Join Date: Oct 2005
Posts: 3,519
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I was advised early on that they have to pay for it until it is right...until you are happy with it. And if that means several surgeries to get to that point, then they must pay. You must make sure that the cosmetic surgeon codes it correctly, too.
After my initial recon, my first implant was not the correct size, it was just a bit too small. We went in a year later to remove scar tissue and at the same time replaced the implant with the proper size. My insurance was responsible for the correction of size, as required by law.
__________________
Brenda
NOV 2012 - 9 yr anniversary
JULY 2012 - 7 yr anniversary stage IV (of 50...)
Nov'03~ dX stage 2B
Dec'03~ Rt side mastectomy, Her2+, ER/PR+, 10 nodes out, one node positive
Jan'04~ Taxotere/Adria/Cytoxan x 6, NED, no Rads, Tamox. 1 year, Arimadex 3 mo., NED 14 mo.
Sept'05~ micro mets lungs/chest nodes/underarm node, Switched to Aromasin, T/C/H x 7, NED 6 months - Herceptin only
Aug'06~ micro mets chest nodes, & bone spot @ C3 neck, Added Taxol to Herceptin
Feb'07~ Genetic testing, BRCA 1&2 neg
Apr'07~ MRI - two 9mm brain mets & 5 punctates, new left chest met, & small increase of bone spot C3 neck, Stopped Aromasin
May'07~ Started Tykerb/Xeloda, no WBR for now
June'07~ MRI - stable brain mets, no new mets, 9mm spots less enhanced, CA15.3 down 45.5 to 9.3 in 10 wks, Ty/Xel working magic!
Aug'07~ MRI - brain mets shrunk half, NO NEW BRAIN METS!!, TMs stable @ 9.2
Oct'07~ PET/CT & MRI show NED
Apr'08~ scans still show NED in the head, small bone spot on right iliac crest (rear pelvic bone)
Sept'08~ MRI shows activity in brain mets, completed 5 fractions/5 consecutive days of IMRT to zap the pesky buggers
Oct'08~ dropped Xeloda, switched to tri-weekly Herceptin in combo with Tykerb, extend to tri-monthly Zometa infusion
Dec'08~ Brain MRI- 4 spots reduced to punctate size, large spot shrunk by 3mm, CT of torso clear/pelvis spot stable
June'09~ new 3-4mm left cerrebellar spot zapped with IMRT targeted rads
Sept'09~ new 6mm & 1 cm spots in pituitary/optic chiasm area. Rx= 25 days of 3D conformal fractionated targeted IMRT to the tumors.
Oct'09~ 25 days of low dose 3D conformal fractionated targeted IMRT to the bone mets spot on rt. iliac crest that have been watching for 2 years. Added daily Aromasin back into treatment regimen.
Apr'10~ Brain MRI clear! But, see new small spot on adrenal gland. Change from Aromasin back to Tamoxifen.
June'10~ Tumor markers (CA15.3) dropped from 37 to 23 after one month on Tamoxifen. Continue to monitor adrenal gland spot. Remain on Tykerb/Herceptin/Tamoxifen.
Nov'10~ Radiate positive mediastinal node that was pressing on recurrent laryngeal nerve, causing paralyzed larynx and a funny voice.
Jan'11~ MRI shows possible activity or perhaps just scar tissue/necrotic increase on 3 previously treated brain spots and a pituitary spot. 5 days of IMRT on 4 spots.
Feb'11~ Enrolled in T-DM1 EAP in Denver, first treatment March 25, 2011.
Mar'11~ Finally started T-DM1 EAP in Denver at Rocky Mountain Cancer Center/Rose on Mar. 25... hallelujah.
"I would rather be anecdotally alive than statistically dead."
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11-05-2007, 10:03 AM
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#4
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Senior Member
Join Date: Feb 2006
Posts: 1,014
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Since I don't have any implants (a lumpectomy was done). I just was wondering if they would think it was foolish to worry about making the other breast match the one that was operated on, since it's not a huge difference. When I was first diagnosed I figured "what the hell", I probably won't be alive long enough to care. But now I am reconsidering this and would like to have breasts that are symetrical. I have a good plastic surgeon, so I think I will contact him and see what he thinks..sherryg
__________________
Sherry
Diagnosed: December , 2005 at age 44
13+ positive lymph nodes
Stage IV , Her2+, 2 small mets to lungsChemo Started: Jan, 2006
4 months Taxotere, Xeloda, Hercepin
NED since April 2006!!
36 Rads to follow with weekly Herceptin indefinately
8 years NED now
Scans every year
Life is not about avoiding the thunderstorms, it's about learning to dance in the rain!
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11-05-2007, 01:55 PM
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#5
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Senior Member
Join Date: Aug 2006
Location: Sheboygan, WI
Posts: 2,582
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For what it's worth, I was told by my insurance company that I have 5 years to decide if I want reconstruction and they have to pay for it. I'm not quite sure what would happen if I opted for reconstruction in year 6 or 7 but that's what they told me. I am not having reconstruction so it isn't something I've ever researched but just sharing what I was told.
Mary Jo
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"Be still and know that I am God." Psalm 46:10
Dx. 6/24/05 age 45 Right Breast IDC ER/PR. Neg., - Her2+++ RB Mast. - 7/28/05 - 4 cm. tumor Margins clear - 1 microscopic cell 1 sent. node No Vasucular Invasion 4 DD A/C - 4 DD Taxol & Herceptin 1 full year of Herceptin received every 3 weeks 28 rads prophylactic Mast. 3/2/06
17 Years NED
<>< Romans 8:28
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11-05-2007, 04:11 PM
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#6
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Member
Join Date: Sep 2007
Posts: 10
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federal law
www.plasticsurgery.org/patients_consumers/links_resources
This explains the law in "non-legaleze". The federal law only relates to reconstruction after mastectomy. And the health insurance must cover any reconstuction or modifications for as long as you are a policy holder, for any reason (so if I decided I want "Dolly Partons" next year my insurance must pay for it). Things change when you switch to Medicare.
Unfortunatley I don't think the law covers lumpectomies. I have a dear friend of 15 years who was diagnosed at the same time I was. As she was ER+/PR-, Her2-, she opted for a lumpectomy. She is trying to get her insurance to cover modification of the lumpectomy sight and reduction of the other breast (she is a DDD cup). So far they have denied her.
I hope this helps clear things up.
__________________
jennifer
dx 6/06
Double mas 8/06
Stage IIa
ER+/PR-, HER2+
Taxotere completed 12/06
Tamoxifen
Herceptin
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11-05-2007, 05:00 PM
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#7
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Senior Member
Join Date: Sep 2005
Location: Simi Valley, CA
Posts: 94
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This is interesting to me as I am STILL fighting my insurance to cover revisions to my reconstruction I started last year. They are saying it is cosmetic and not covered. Anyone know HOW to enforce this law on your insurers? I've appealed and appealed and they've now approved revisions to my left breast but not my right - even thought they covered a right proph mastectomy last year. VERY frustrating, especially when I hear things like this about they have to cover it until you're satisfied. I would check with them thoroughly before you do anything. Good luck! Anyone else got any suggestions?
Jen
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Jen
DX 10/04 IDC Grade 3
ER/PR-, Her2+++
4/20+ Lymph nodes
Stage 3a
Age 38, CA
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11-05-2007, 06:35 PM
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#8
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Senior Member
Join Date: Oct 2006
Location: Louisville KY
Naples FL
Posts: 665
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Sherry
I have the exact same problem. I had a lumpectomy also and they
do not match at all now. My surgeon said any surgery will be covered
but I can't make up my mind. It has been 15 months.
patb
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patb
Diagnosed June, 06, Stage I, Grade3, ER+PR- Her2positive, No Nodes. A/C X 4. Radiation 33 with boost, Herceptin every two weeks until Nov.
07, Arimedex for 5 years. Mugas and Echo and chest xRay. Bone scan of whole Body, and Back of Brain and spine MRI.
CT scan of Lungs every six months
due to two small places. December
2009, bone scan due to bone pain.
Follow up test in 2010.
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11-05-2007, 07:21 PM
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#9
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Senior Member
Join Date: Dec 2005
Location: Michigan
Posts: 230
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Sherry,
My mother in law had this problem and she had reduction of the other breast all covered by her insurance because it was considered "reconstructive from breast cancer surgery. I can also tell you she has been very happy with the decision.
Good luck.
Mar
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Mary
Diagnosed 11/04 @39yrs. young
Stage IIB
2.5 cm, ER/PR- Her+++, grade 3
Partial Mast., 1/3 pos. node
1/05 full node dissection
4 A/C 4 Taxol DD, Herceptin 1 yr.
30X rads.
BRCA Negative
NED
Hope is the thing with feathers
That perches in the soul,
And sings the tune without the words,
And never stops at all -Emily Dickinson
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11-05-2007, 09:26 PM
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#10
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Senior Member
Join Date: Feb 2006
Posts: 1,014
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I have an appointment with my plastic surgeon for next week. His nurse said that she believed that insurance would only pay for corrections on the breast that had the lumpectomy and not reduction of the other. But also said that if they had to do any work at all on the effected breast that they then could reduce the other one and it be covered. She was not positive about this. I have great insurance who has never denied me anything, so we will see. I definately do not want an implant, just a little litle liposuction to the other one. Maybe they might have to do some scar revision or something to make the insurance thing work. ...sherryg
__________________
Sherry
Diagnosed: December , 2005 at age 44
13+ positive lymph nodes
Stage IV , Her2+, 2 small mets to lungsChemo Started: Jan, 2006
4 months Taxotere, Xeloda, Hercepin
NED since April 2006!!
36 Rads to follow with weekly Herceptin indefinately
8 years NED now
Scans every year
Life is not about avoiding the thunderstorms, it's about learning to dance in the rain!
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