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Medicare Coverage for Exams following Mastectomy

Posted by justlucky @justlucky, 5 days ago

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).

Interested in more discussions like this? Go to the Breast Cancer Support Group.

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smith777 | @smith777 | 2 days ago
In reply to @justlucky "@smith777 - thank you for your concern and suggestion, Susan. Actually, my current MD is in..." + (show)
Profile picture for justlucky @justlucky

@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.

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@justlucky Hi

Very sorry to hear about the difficulty you are experiencing. I can imagine how frustrating , annoying and worrisome this must be for you.

I experienced similar issues. If you google the MD President and MD Associate Director of the Medical Center in AI mode you will probably generate the Name, Titles, ,E mails etc .

I received a one day response follow up re scheduling after I emailed the MD Vice President and Associate Director of the Medical Center in NYC.

Google AI mode will generate names and e mails that are very difficult to obtain otherwise.

Another option is Google AI mode for the names and e mails of the members of the •• Ethics Committee at your medical center.

Added option: Cancer Care may possibly advocate for you .

I feel badly that you have to deal with continuing obstacles to reaching MDs or administrators at your hospital in order to resolve matters. I experienced similar difficulties and empathize with your frustration and disappointment and stress.

Hopefully , Google AI mode will generate very high level MD Administratuve Names and direct E mails as contacts and resolve the issues and Cabcer Care may advocate for you

Added option: NEWS Channel On Your Side or similar News Investigative Reporters that assist the public. Your health care is critical!

Best 🌸

Susan

REPLY
Profile picture for smith777
smith777 | @smith777 | 2 days ago
In reply to @justlucky "@smith777 - thank you for your concern and suggestion, Susan. Actually, my current MD is in..." + (show)
Profile picture for justlucky @justlucky

@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.

Jump to this post

@justlucky

REPLY
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smith777 | @smith777 | 2 days ago

Hi

I researched this contact: On Your Side News- Investigative Reporting.

The stress of bills and a hospital not resolving the issues may be very stressful!

I can image how stressful this is for you.

I believe contacting On Your Side News may result in their possible television coverage and hopefully induce the hospital to resolve the financial matters for you.
——-

—-

Contact us
WNCT/ENCT

3221 South Evans Street

Greenville, NC 27834

🔵. 252-355-8500

🔵 newsdesk@wnct.com

Jacksonville bureau:

Address: 406 S. Marine Blvd., Jacksonville, NC 28540

WNCT.com is 9 On Your Side online in all of eastern Carolina, known and respected for breaking news, weather sports, and streaming video. WNCT.com is a powerhouse in digital media on multiple platforms: mobile, social media networks, blogging, email and text alerts.

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1 reply
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justlucky | @justlucky | 1 day ago
In reply to @prarysky "@justlucky Such good advice! I am also 75. Although we'd long dreamed about moving to the..." + (show)
Profile picture for prarysky @prarysky

@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

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@prarysky - So true. Thank you for the link.

And a more general comment for all...when I was first treated in my last location, I learned of a BC support group run by one of the hospital's nurse social workers. They met monthly to talk about a range of topics. It was a really helpful forum. At first glance, it seems this Mayo group is an online version. I'm glad I found it. 🌺

REPLY
Profile picture for justlucky
justlucky | @justlucky | 1 day ago
In reply to @smith777 "Hi I researched this contact: On Your Side News- Investigative Reporting. The stress of bills and..." + (show)
Profile picture for smith777 @smith777

Hi

I researched this contact: On Your Side News- Investigative Reporting.

The stress of bills and a hospital not resolving the issues may be very stressful!

I can image how stressful this is for you.

I believe contacting On Your Side News may result in their possible television coverage and hopefully induce the hospital to resolve the financial matters for you.
——-

—-

Contact us
WNCT/ENCT

3221 South Evans Street

Greenville, NC 27834

🔵. 252-355-8500

🔵 newsdesk@wnct.com

Jacksonville bureau:

Address: 406 S. Marine Blvd., Jacksonville, NC 28540

WNCT.com is 9 On Your Side online in all of eastern Carolina, known and respected for breaking news, weather sports, and streaming video. WNCT.com is a powerhouse in digital media on multiple platforms: mobile, social media networks, blogging, email and text alerts.

Jump to this post

@smith777 - Thank you for your research! I'm familiar with "On Your Side" in my area, connected to the NBC affiliate station. They do very good work. I've contacted them for a couple of home-related issues. I'm on a first name basis with their producer. Your suggestion is timely. I thought about contacting them yesterday. The biggest drawback for engaging them is that it means going public, my anonymity would be gone. If this involved thousands of $, it might be worth it. For now, I'd like to keep my issue resolution within the system. But I thank you for thinking of this!

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