Medicare Coverage for Exams following Mastectomy

I’ve been told that Medicare has been paying less and less every year. We seniors have paid into the system all our working lives to now be facing denial of many medical procedures and tests as prescribed by our doctors. Like all, my insurance costs have increased significantly and many drugs I find being prescribed by doctors are in much higher tiers in 2026 than previously. It all takes a toll worrying not only about our diagnosis but in affording the treatment. So maddening. Sorry this is no help but I hope you find answers soon.

If your implants are silicone, surveillance is recommended to be sure they are functioning properly. Since your reconstructive surgery was the result of breast cancer and not cosmetic, I thought Medicare paid. Perhaps the new plastic surgeon needs to emphasize that your visit was not "routine" but prescribed surveillance following breast cancer reconstruction.

Your doctor probably did state this was the case but I'd double check to be sure. It's exhausting having to battle with insurance, but I think you have a legitimate basis for appeal...again!

@prarysky - Thank you. Yes, silicone. I spoke with the Admin in my previous MD's practice and learned a few things. First, "recommended" is not enough justification for insurance coverage. Second, ICD-10 codes keep changing. Third, they receive more requests for documentation to justify claims than they used to. Fourth, although they have had issues with denials (with companies such as United Health), not with Medicare. That tells me I should expect Medicare will cover the exams. She gave me the ICD and CPT codes they use. They are different than what the current provider uses.
My current provider's system is huge (a giant in the industry). There is one number and one email address for patient relations - for all practices, not just oncology. I get someone different every time I call. The Admin in the current practice told me yesterday his "knowledge around this complicated claim is unfortunately limited." He is working to find someone else for me to contact.* If he thinks an annual exam is complicated, how in the world can he handle truly complicate issues?
(*UPDATE: while writing this the manager who handles billing escalations called. She confirmed they used different codes. After a lengthy conversation she will attempt to resubmit the claim using the codes I obtained. If that doesn't work, she will cancel/forgive the outstanding charge. Although I appreciate the concession, I said I will not return for another exam unless this has a permanent resolution.)
Stay tuned for more updates. Thanks to all for your support!

If you have BCBS you either have a Medicare Advantage program managed by BCBS or a Medicare Supplemental from BCBS? If you were only on Medicare, BCBS wouldn’t be involved in approvals.
Pure Medicare might have better coverage than a BCBS managed program. I’ve had to sift through multiple providers and Medicare coverage for myself, husband, and sister. She used to use Medicare through Aetna. My husband used to use Medicare through UHC. Each have different coverage, and are different than choosing to just use Medicare alone.
It could be that BCBS is the coverage that is limiting your options. As I understand it, Medicare alone continues to pay for breast cancer follow ups, BC related breast changes, and scans.

If you want to make a change to a medicare advantage program you still can. Although I would check to see that there were no penalties, or increase in Medicare costs before doing so. These shouldn't be a problem, but it depends on individual circumstances.
“The main period to change Medicare Advantage plans is the Medicare Advantage Open Enrollment Period (MA OEP), running annually from January 1 to March 31, allowing one change to another MA plan or back to Original Medicare.”

@triciaot - yes, I know that. It's Medicare that has denied the claim 2x. BCBS isn't involved; they are not the issue. Not looking to make an insurance change for supplemental, but thanks anyway!

So sorry that you are experiencing such difficulties with billing . I can imaging how stressed, worried and frustrated you may feel.

I feel very badly for your experiencing such difficulties.

Have you considered changing your medical and surgical care to a hospital based MD? Hospitals maintain billing specialists, patient advocates and social workers who would advocate for you and work toward resolving the billing code issues.

I hope this suggestion is helpful.

Best,

Susan

This is an example of the incredible navigational skills required by patients using health care insurance of all kinds. Persistence and patience are not something patients dealing with major health concerns may have.

I attended an online program sponsored by Triage Cancer about health insurance. In it they said a very small proportion of patients appeal decisions when coverage is denied. This program was addressing private insurance and not Medicare. They also said that of that small proportion of people who DO appeal, however, assuming they have the documentation from their provider supporting their claim, the vast majority do win on appeal.

Others have offered some helpful advice here that applies to many others.

I think your bill will be resolved in your favor but also wish you an easier claim process in the future, perhaps with a different provider.

@smith777 - thank you for your concern and suggestion, Susan.

Actually, my current MD is in a university hospital system. I've read they are the 2nd largest employer in the state with at least 4 hospitals, 140+ locations and many specialty practices. I live in NC, which may give you a hint as to which hospital system it is. I actually think the system's size is part of the problem - impersonal and siloed. I escalated to patient relations in October and after a couple of conversations and emails, that advocate disappeared, never to be heard from again. On this and other issues I reported, her role appeared to be that of a traffic cop and to tell ME what else I should try. In fairness, she did engage the Dir. of Outpatient Oncology who promised to be my contact but has not replied to my last 2 emails since November. I learned she delegated this to the practice Administrator and he's the one who told me this was too "complicated" for him. Very sad and frustrating.

Please see my reply to @prarysky to follow for more comments about system and provider.

@prarysky - Thank you for your comments and understanding.

You are so right! Never did I ever think I needed to learn about ICD-10 and CPT codes! I should have tracked how many hours I've spent on this one claim so far. It's enormously time consuming. Just this week I've probably logged 4-5 hours. I turned 75 last year and the day will come when I can no longer handle research and follow-up - for this or any other medical situation.

That's interesting feedback about the program you attended. I'm single and I learned a long time ago I need to be my own advocate for everything because no one else will be. Plus I don't have $495 (the amount of the 2023 denied claim) or $223 (the current denial) to just throw away. So I push.

Regarding the current provider....I thought I had found a needle in a haystack when I connected with her. After I moved, I must have contacted a dozen MDs, trying to establish a relationship. Although I was not in need of immediate care, I didn't want to wait to find someone when/if something happened to my implants. It was the internet version of picking an MD out of the yellow pages. Not the best way to pick an MD. I spent many hours on the internet calling every plastic surgeon in the area who does breast surgery. My requirements were not extreme. I needed someone who 1) took insurance (of any kind - some I learned do not), 2) accepts Medicare, 3) has solid credentials, and 4) accepts patients who do not need surgery or other cancer treatment currently (remember my reconstruction was done in 2005). When I did stumble upon my current MD within the same health system of my other providers (hence, all records were available), her first opening was 10+ months later. Only with the assistance of the Dir. of Patient Relations did I net an appointment that was "only" 4 months out. I felt extremely lucky. Therefore, the idea of going in search for another provider would be a last resort.

I tell you this (and all others reading my sad tale) only because it should be a consideration for any survivor who is planning a move outside of the geographic area where she originally received treatment. I don't live in the boondocks. It's not the major metro area I came from but it's not the sticks either. Little did I know finding a new provider would be one of the challenges of relocation that I would face!

@justlucky
Such good advice! I am also 75. Although we'd long dreamed about moving to the wider open spaces beyond a metropolitan area, those are now fantasies. I've read of retirees moving to towns in Arizona or Colorado only to find doctors are reluctant to take on more Medicare patients in areas of high Medicare enrollees.

That is no surprise given the relatively low Medicare reimbursement rates to many doctors, especially those in primary care fields. We also have had to rely on the emergency room more than when we were younger, so now appreciate that we are close to good hospital emergency rooms.

There are many troubling issues with health care access bubbling up and already here. There is maldistribution by specialty and geography. There has been for decades but it seems worse today. There also seems to be a bottleneck in training programs, e.g., a lack of nursing programs.

In case this may be useful, here's a link to Triage Cancer. They provide all kinds of useful information and it is not just limited to cancer, though that has been a primary focus:
https://triagecancer.org