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Medicare Coverage for Exams following Mastectomy
Breast Cancer | Last Active: 1 day ago | Replies (15)Comment receiving replies
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.
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@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!