Breast Cancer Survivors May Face Insurance Challenges For Reconstruction

Breast Cancer Survivors May Face Insurance Challenges For Reconstruction

Few things can impact someone's life quite like cancer. And those who survive breast cancer are often left feeling a wide range of emotions due to their battle - and their victory. But while it's certainly good news to be a survivor, some challenges may still remain.

Breast implants, expanders, and reconstructive surgery are something that is often used by survivors as they work to regain their confidence and their identity following a mastectomy. While some may decide to forego these procedures, a majority of women feel that it's important to have reconstructive surgery. Thanks to modern medicine, this is a fairly simple, straightforward process. But what may not be as simple as getting help from insurance companies when you need to pay for the reconstruction.

In short, not all insurance providers will be willing to pay for breast implants and reconstruction following a mastectomy. Despite the fact that the operation can be considered as part of a necessary, life-saving procedure, there are simply some cases where a patient may face an uphill battle to get the help they need.

The issue is that there isn't a specific HCPCS code for tissue expanders or sizers. There are codes that apply to miscellaneous surgical supply or for special materials, and these can sometimes be used during a filing. HCPCS C1789 could be reported to Medicare for a prosthesis during a breast implant surgery, and then reimbursement may be included in the payment for the procedure. Non-Medicare patients will want to use l8600 for the implants. However, different plans offer different coverages and these may not always be approved.

A problem with this is that in many cases, implants or tissue expanders aren't always set aside as a separate reimbursement by some providers. They may be looked at if they make up more than 25% of a reimbursement, but often this doesn't provide adequate coverage and patients are left footing the bill for their reconstruction themselves.

It's worth noting that at the moment, private insurance providers will often pay for more than Medicare will, providing more relief from the financial burden of a reconstructive surgery. But there can still be a challenge not only getting reimbursement but even figuring out how to go about doing so.

Luckily, this is something that those in the insurance industry are aware of, and surgical trends often shift procedures to outpatient centers which may end up being billed differently under different codes as well. This can make some reimbursements more challenging, but it's also raised visibility on some insurance issues such as this.

The bottom line is that talking to an insurance provider should be something that any patient does. Following a lifesaving procedure, getting the reconstruction needed to feel like the person you once were is important and patients shouldn't have to foot the bill themselves. For now, an insurance professional can help offer the best guidance on the issue. Hopefully, soon, all facets of a reconstruction will be covered under insurance - including Medicare.

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