Reconstruction for a double lumpectomy/no cancer, not covered by insurance?

Question

Had a double lumpectomy 10 days ago. The 2 golf ball sized tumors turned out to be non cancerous. My once DD breasts now have 2 huge dents and little to no firmness.I had stitches removed today & asked about reconstruction. She NOW tells me it may not be covered by insurance & that I need to wait until my 3 month scan. Why wait if there was no cancer? And will I have trouble getting this covered? If it would help the claim I would even be fine reducing my size to a C cup to regain firmness/lift.

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question! Contour deformities or asymmetry between size/shape of the other breast following lumpectomy and radiation may occur after everything settles and is not an uncommon scenario following lumpectomy.  There are several options to ameliorate this and you should discuss your options with your plastic surgeon to determine which option would be best for you. It is recommended to wait approximately 6 months to one year after your radiation therapy is completed before considering any reconstructive procedure on the breast.Typically, implants in the setting of an irradiated breast has higher rates of complication, including infection, wound complications, capsular contracture, etc. Many surgeons, including myself, have placed implants to improve symmetry in these instances with excellent results. However, if your deformity is a contour issue with a soft tissue deficiency, placing an implant beneath the breast may actually worsen the deformity as it is not addressing the issue to "fill" the defect. For such problems, it may be a wiser decision to consider fat grafting for smaller defects, where fat is harvested for another area of your body and then reinjected into the defect, thus adding volume as well as having the added properties of fat graft stem cells. Autologous flaps such as local tissue, TAP, or LDMF may be needed for larger soft tissue defects.  Of course, reduction of the other breast to create symmetry is an option, or a combination of procedures on both breasts. Typically, reconstruction for history of breast cancer is covered. Yours is a little tricky, but discuss options and your complaints with your surgeon. Best wishes!

M. Scott Haydon, MD · Answer

Thanks for your question. Normally, the plastic surgeon doesn't get an approval for reconstruction because it is done following breast cancer. Insurance carriers are obligated to provide coverage to reconstruct breasts if there has been cancer present. In your case, you need to see a plastic surgeon who will write a letter of medical necessity. They can include your pictures. Hopefully you can get something approved. It might take several months and appeals. Your breast surgeon should be willing to help with this too by submitting a letter on your behalf. Best of Luck!

Morgan E. Norris, III, MD, FACS · Answer

While the Women's Health and Cancer Rights Act of 1998 does mandate
that breast reconstruction be covered when it is related to breast cancer it does
not mandate coverage for breast reconstruction when it is related to anything
other than breast cancer.  Unfortunately
this means that you may have trouble getting your insurance company to provide
coverage for procedures to correct the contours of your breasts.  This is a common challenge of women who have
undergone lumpectomies and were not diagnosed with breast cancer.  I recommend speaking to your human resources
department or to your insurance company directly to find out what is and is not
covered on your insurance plan.Be well and good luck!@norrisplastic

Samir Shureih, MD · Answer

Breast Reconstruction after lumpectomy is much more difficult and require significant experience to do the reconstruction and choose the right procedure.Even in cancer patients I have seen insurance companies deny reconstruction after lumpectomy. If the lumps were benign the insurance company will not cover the reconstruction in most cases. Waiting three months does not change the coding diagnosis. If you are a candidate for breast reduction and meet the insurance criteria and is medically indicated, the breast reduction may improve the lumpectomy problems, it may not. It is not your doctor's fault, your doctor did the lumpectomy for large masses of the breast to make sure he/she does not miss a cancer diagnosis. The decision for reconstruction is that of the insurance company. Argue your case with the insurance company, the insurance commissioner in your state may help with the insuranceGood LuckSamir Shureih MD. FACSsshureih@msn.com

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