[MOL] Coverage for Preventive Mastectomy..... [02407] Medicine On Line

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[MOL] Coverage for Preventive Mastectomy.....

Coverage for Preventive Mastectomy
by David Lack
Q.My OB-GYN and a surgeon have both told me I need a preventive bilateral mastectomy. But Medicare won't pay for it, and thus Medicaid won't either. Is there some appeal process to go through to try and make this happen? I have no money, and a strong family history of cancer.


A. Medicare, the government-run insurance program for senior Americans, pays for a specific set of medical services. While complex, the covered benefits are defined and specific. In many cases, there is room for appeal and negotiation. Generally speaking, however, it is difficult to receive payment confirmation for medical services not covered by the plan.

The Medicare program does include a set of preventive-care services, but most of these fall into the testing category, such as a mammogram or prostate screening. Medicare does not cover surgical procedures, such as a mastectomy (breast removal), when symptoms are not present. In other words, a mastectomy is not considered preventive care. There must be a disease process present for Medicare to cover a mastectomy.

This may seem shortsighted to some people, especially those advised by their doctor to have a mastectomy even in the absence of any breast cancer symptoms. To many others, just having a history of breast cancer in one's family, however strong, is insufficient to warrant something as drastic as a bilateral mastectomy. One group will ask, "What if I develop cancer?" The other group asks, "What if you don't?" Medicare sides with the latter group and does not pay for surgery where no disease is present. Included in the reasoning is this: Surgery, especially something as extensive as a bilateral mastectomy, is a dangerous event. Why take the risk if there is no disease -- just a suspicion that the disease may develop in the future?

Medicare counselors and claim administrators (many of whom are nurses), agree that this rule is non-negotiable. At the same time, they advise that people in this position should ask their doctor to call the Part B Claim Center physician line for their region. Call 1-800-MEDICARE (633-4227) and ask for the correct toll-free number for your region. After the physician describes the particulars of the case, the Medicare administrator may decide that the surgery should be covered.

The other piece of advice from Medicare administrators is to get a second opinion. Medicare benefits include a second opinion, and for crucial medical decisions, a second opinion is a good idea in any case. Discuss with your physician the pros and cons of "preventive" surgery, ask all your questions, and seek to have your doubts and concerns addressed. Finally, keep up your regimen of visiting your doctor to monitor your health. If Medicare will not pay for a preventive bilateral mastectomy, make sure that you are in a position for early detection.

For more information and important phone numbers, visit the Medicare web site. There you will find information on the State Health Insurance Programs. They can answer your questions about your health plan choices, how to appeal payment denials, and your Medicare rights/protections.

Created on March 27, 2000
Last Reviewed on March 27, 2000

Warmly, lillian
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