I have breast cancer, and will undergo mastectomy, but my insurance will not approve the use of Alloderm for the reconstruction because they say its investigational. If this is the case, what are my other options?
Breast Implants vs Tissue Fillers for Breast Reconstruction
Doctor Answers (19)
Breast Reconstruction can be done without AlloDerm
If you haven't done so already, talk about this with your plastic surgeon. Breast reconstruction can be done without AlloDerm. AlloDerm is a product made by LifeCell. It is a "regenerative tissue matrix" produced by removing the living cells from harvested cadaveric epidermis and dermis. "The cells responsible for immune response and graft rejection are removed. What remains is a matrix or framework of the natural biological components, which allows the body to mount its own tissue regeneration process."
These quotes are from the AlloDerm website. In breast reconstruction, this is often used to help to line the pocket in which an expander and subsequently an implant will sit. Prior to the widespread use of AlloDerm, plastic surgeons created this pocket using your own muscle and tissues in the area, i.e. your pectoralis and serratus muscles that make up your chest wall. This "total submuscular" pocket provided good results for many years prior to the advent of AlloDerm. The AlloDerm makes it easier and possibly more reliable for the surgeon. There are also many other options including autologous tissue reconstruction and combined autologous and alloplastic reconstruction. You should discuss all of these options with your plastic surgeon prior to proceeding.
Good luck with your reconstruction and I hope you have a speedy recovery.
Alloderm Use in Breast Reconstruction Post Mastectomy - Insurance Issues
Alloderm (acellular dermal matrix) has been used more than a decade for breast reconstruction and should not be considered investigational. I would appeal the decision and have your plastic surgeon be your advocate and write a letter of necessity regarding its usage in your particular case. Finally, even if you loose the appeal you should only have to pay the cost of the material (cheaper if the surgeon purchase it for you than the hospital which typically doubles (or more !) the price.
Here is the basics of the federal law:
Women's Rights for Breast Reconstruction Following Mastectomy
The Federal Women's Health and Cancer Rights Act of 1998 is still the law today
Under the federal Women's Health and Cancer Rights Act of 1998, a yearly notification
of your benefits pertaining to breast reconstruction must be sent to you by your insurance company.
The Women's Health Care Act states that benefits must be provided for:
Reconstruction of a surgically removed breast
Surgery and reconstrcution of the other breast to produce a symmetrical appearance
Prostheses and treatment for physical complications from all stages of a mastectomy, including lymphedema
These benefits are subject to the conditions and terms of your plan, including maximum benefit amounts, deductibles,
copayments, and coinsurance provisions. The benefits are subject to your plan's exclusions and limitations.
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Alloderm is not Investigational
Use of an acellular dermal matrix such as Alloderm has become widely utilized in breast reconstruction. If your surgeon feel that it will provide you with an improved outcome then it should be utilized. It may take a few phone calls and letters, but your insurance company should be able to be educated.
Use of Alloderm in implant-based reconstruction
Alloderm has been used for many years with a proven record. It is not investigational nor experimental. There are many articles that testify for benefits of Alloderm and other dermal matrix. I would have your plastic surgeon be your advocate and contact your insurance company again. Best of luck to you.
Alternative to Alloderm in Breast Reconstruction
Although insurance coverage for Alloderm (and other similar products, called collectively Acellular Dermal Matrix, aka ADM) is becoming more common, some payers may not cover it due to the high cost of the product. If your surgeon feels that you could benefit from it but cost is an issue, a much less expensive option is using Vicryl mesh (same material from which some sutures are made). While it does not have all the advantages of ADMs, it can accomplish the same result for creating a more natural breast reconstruction and allow for faster tissue expansion. At least one medical paper has been published demonstrating the positive results of this product.
Alloderm in Breast Reconstruction
The use of Alloderm in your implant-based reconstruction plan is NOT experimental. There is ample data to support its use and its is one of the options for breast cancer mastectomy reconstruction. I would speak with your plastic surgeon and have them serve as your advocate. In addition, I would recommend that you contact your insurance company to fight this nonsense. Despite the 1998 federal law mandating mastectomy reconstruction coverage, on occasion, some pesky insurance companies continue to look for ways to reduce or deny covered services. This is exactly when patients and physicians need to team up and battle this nonsense.
Alloderm and breast reconstruction
While breast reconstruction has been around for a long time before Alloderm, more and more surgeons are using it for their breast reconstructions. Insurance companies are about saving money. They like to label things "experimental" so they do not have to pay. Remember it took an act of Congress to get them to pay for breast reconstruction at all, and another act of Congress to get them to pay for the other side. Having said that, Alloderm is not experimental. It is in common usage, and has good studies to back it up. Enlist your plastic surgeon and appeal the denial. Often the alternative reconstructive option, (rotational flap or free flap) is more costly and then the insurance company may want to go the Alloderm route.
Insurance Coverage for Alloderm Use in Breast Reconstruction
Although AlloDerm certainly has a proven track record for use in breast reconstruction surgery, some insurance companies will try to deny it as experimental in order to avoid coverage.
DO NOT BE DISCOURAGED!
This is when your surgeon needs to be your advocate.
1. The Women's Health Care Act of 1998 requires that any insurance company that covers mastectomy must also cover all stages of reconstruction and matching surgery.
2. Lifecell corporation, who makes AlloDerm, has a reimbursement hotline to help deal with these issues- LifeCell Reimbursement Hotline at 888.543.3656 or email@example.com.
3. If you work for a large company, your Human Resources Representative has significant clout in working with your insurer.
4. Breast reconstruction is a hot political and media issue. Getting your local press involved is a powerful form of ground roots activism for yourself and others.
Alloderm not approved by insurance
Insurance companies commonly categorize certain treatments or adjuvants as "investigational" and do not cover the cost of using them. Thankfully, most insurance companies are approving Alloderm usage in breast reconstruction due to the large numbers of positive studies regarding its use. If your insurance company does not cover Alloderm, you have a few options:
- Have your Plastic Surgeon contact the insurance company for pre-authorization - this usually requires a letter including copies of studies purporting the use of Alloderm
- Contact the insurance company yourself. Sometimes, the coverage policies displayed on the websites are not up to date and they may have recently begun covering Alloderm
Reconstruction with tissue expanders can also be done without the use of Alloderm. This involves covering the lower portion of the implant with other muscles adjacent to the pectoralis muscle (the serratus anterior and the rectus sheath). Have the discussion with your surgeon as to the pros and cons of each and whether the fight to get your insurance company to cover the Alloderm is worth it!
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.