Medical Insurance and a Prophylactic Mastectomy

Question

I have a very very strong history of breast cancer in my family.My maternal grandmother died from breast cancer and so has my maternal aunt.My mother was diagnosed at 45 and is still battling it.I also have a sister who has it.I am very set on having this done I have had the gene test done but am the only one in my family to.I have also had 2 lump removels and 2 core biopsies.I am dead set on this will it be hard to get the doc to do it?I also have told my oncologist what I want.Will medicare pay?

Stanley Okoro, MD · Answer

Your medical insurance should cover the cost of bilateral prophylactic mastectomy and breast reconstruction if you meet of the medical criteria. You should see a breast oncologic surgeon and Plastic surgeon to help you with this situation. This is not a battle to fight by yourself. If you do not get the help you need and deserve, please get another opinion.

	Good Luck

	Dr Okoro

Shitel Patel, MD · Answer

Simple answer is YES! Medicare will cover the prophylactic mastectomy and reconstruction with your significant family history of breast cancer. It is the law! Please go to a board certified general or plastic surgeon or both to be evaluated. Good Luck!

Larry S. Nichter, MD, MS, FACS · Answer

In most cases with a strong recommendation from your oncologist, internist and general surgeon your prophylactic mastectomy will be covered. What will definitely be covered is your post mastectomy reconstruction. Here is the 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.

Otto Joseph Placik, MD · Answer

There are two issues here: oncologic management of your disease and options for reconstruction. I would consult with your oncologist regrarding an oncologic surgeon willing to perform a prophylactic mastectomy. The reconstruction is another issue. Medicaid may pay for both but the reimbursements are exceptionally low and many surgeons cannot afford to run their practices with these types of payments. Therefore few will participate. You may seek treatment through a University setting.

Paul Gill, MD · Answer

Based on your family history, I agree that this is an option for you to consider.  It is important to consult with a medical oncologist, breast surgeon, and reconstructive surgeon to have them document the medical necessity and indications for this procedure.   This should all be submitted to medicare for approval.  The process may involve appeals and further letters, but should be covered with the appropriate documentation.   I also find that the insurance company typically responds very well to patient phone calls and letters.    I think this is definitely possible, but take an active role as the patient and load the ship with documentation/letters from your doctors.  All the best.

	 

	Paul S. GIll, M.D.

	Gill Plastic Surgery

	Houston Double Board Certified Plastic Surgeon

Gary D. Breslow, MD, FACS · Answer

Your breast surgeon should be able to get the appropriate documentation togther to have the surgery covered under Medicare.

Darryl J. Blinski, MD · Answer

It is a process to have medicare cover a prophylactic simple mastectomy. Very hard but not impossible to accomplish. Find a PS who is willing to "go to bat" for you with Medicare. Regards and good luck Dr. Darryl J. Blinski

Karen M. Horton, MD · Answer

If you have breast cancer OR a significant family history of breast cancer, then by law all insurance companies are required to cover whatever cancer surgery you need (i.e. lumpectomy or mastectomy), AND the breast reconstruction option of your choice.

	If you do an Internet search of "breast reconstruction law" you will come across the legal history and current law from 1998 which describes your rights.

	Given your family history, I would recommend that your Family Doctor or OB-GYN refer you for the BRCA (breast cancer) gene test.  Not all breast cancers that run in families are BRCA-1 or BRCA-2 gene positive, but if you are a carrier for this gene, then you can find out what your more specific risk for developing cancer is.

	BRCA-positive women also are at risk of ovarian cancer.  Speak to your Physicians about this as well.

	Despite the fact that insurance covers surgery (such as Medicare), unfortunately not all Physicians accept all types of insurance, particularly Medicare.  Decreasing reimbursements for surgery have forced many Doctors to stop taking patients with plans that do not cover their overhead expenses. 

	You may have to do your homework and find a Doctor who accepts your plan, or alternatively, consider accepting some out-of-pocket expenses in order to get the exact procedure and Providers you want.

	Best of luck to you.

	Karen M. Horton, M.D., M.Sc., F.R.C.S.C.

Steven Wallach, MD · Answer

If you have a strong family history of breast cancer the insurance company will probably cover your procedure.  But you should cheeck with them first.

George J. Beraka, MD (retired) · Answer

Hi.

	We do this all the time, and our patients get insurance coverage.  I don't understand why your doctors would be reluctant to do this.

Medical Insurance and a Prophylactic Mastectomy

Answers (10)