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Medicare Coverage for Exams following Mastectomy
Hello,
I'm new to this group. 21 years ago this month (January 2026) I was diagnosed with DCIS in both breasts. I had a bilateral mastectomy with reconstruction. I am well!
For the first 14 years I had checkups (every 1-2 years) with the same breast plastic surgeon to ensure the integrity of the implants. Starting with year 14 my insurance has been Medicare and BCBS and the exams were fully covered. Then I moved out of state. After locating a new plastic surgeon my next checkup was at year 18. The exam was denied by Medicare. After escalating to the executives of the medical system, the claim was recoded and paid by Medicare. It took 2 months to correct. The next year the exam claim was processed by Medicare without issues. Now, in year 20 (2025), Medicare again denied the latest exam claim. The provider's financial and billing teams revised the claim coding and resubmitted for processing. 4+ months after the exam I have again been told that Medicare denied the claim a 2nd time, as has BCBS. I have not received anything nor can I see on my Medicare account anything about the denial reason for the revised claim. I only have an email from the provider's practice administrator. (The first 2025 Medicare claim denial indicated it was a "routine" exam and therefore not covered.)
Has anyone else experienced issues with Medicare denials after reconstructive surgery? If so, I could use your advice on how to resolve this (other than moving back my home state and being cared for by my original surgical team).
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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.
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3 ReactionsIf 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!
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2 Reactions@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