Bi-lateral Reconstruction with S-Gap procedure...Insurance P

Sue Koch · New User Joined: 13 Mar 2005 Posts: 5

Breast Reconstruction Out of Network Provider What is this ?

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Author
Sue Koch
New User

Joined: 13 Mar 2005
Posts: 4

Posted: Mon Dec 11, 2006 7:12 pm Post subject: Breast Reconstruction Out of Network Provider

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Hello All,

Last April, I attempted to obtain permission to have a surgeon that performs Bilateral Breast Reconstruction using the S-Gap procedure. (taking tissue from the buttocks when there is not enough abdominal tissue) perform the Bilateral on me. There are only a few surgeons in the U.S. that perform the S-Gap procedure(one side done at a time requiring two operations) and even less that do the bilateral S-Gap where both are reconstructed at the same time.

The procedure is not considered experimental and my Insurance will approve having an in-network surgeon do the Unilateral S-Gap procedure which means two major surgeries, two anesthesia's, two hospital stays, two recuperations, etc. I cannot believe that an Insurance co. would not see the benefit of doing the Bilateral S-Gap. It is more cost efficient by the way.

The surgeon I would like to do the surgery pioneered the Procedure 10 years ago and has performed hundreds. The surgeon I went to "[in-network) at Johns Hopkins had only performed ten unilateral S-Gaps in the last seven years. My Insurance would approve this.

I appealed , even appearing in person and was still turned down as they said there were others in network I could see. No, they do not perform the Bilateral.

How can they justify me being a "guinea pig" by having the surgery performed by a Dr. who has only performed a few and also requires two surgeries, etc.? Has anyone encountered the same problem and successfully had the Insurance Co. cover the surgery? Also, this Dr. will work with the Insurance Co. as far as providing a compromise. He refuses to become an "in-network" provider because of Insurance Co.s preventing women from being able to have this procedure done. I do not want to have to visit the few Dr's on the list, up and down the East Coast. I live in VA. I teach school and don't have the time to drive all over creation, meeting with their doctors.

By the way, the Dr. at Johns Hopkins had a lousy bed-side manner. Did not want me asking questions, just leave everything to him. I took copious notes and presented the info. The review Booard understood why I did not want to have him do the procedure. However, because I haven't checked with other Dr's., no deal. Does anyone have any advice? I would be most appreciative of any help or suggestions.
Thanks so much.

Sue in VA

Cindy · Senior User Joined: 01 Dec 2004 Posts: 156

Hi Sue. Look up, read and print out a copy of the Women's Breast Cancer Rights Act of 1998. By law, the insurance company has to provide coverage for mastectomy and reconstruction on the cancerous breast...AS WELL AS, surgery on the other breast to provide symmetry. Now, if it takes S-Gap on the other breast to provide symmetry, which the act does not define, then it would have to be covered. I would give the insurance company a copy of the act and circle the part about the symmetry. It's worth a try. Good luck!

Cindy
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