Breast Implant Reconstruction and Acellular Dermal Matrix and Insurance Company Battle

Ok, now I’m really shocked and angry!

As many know, breast reconstruction has always been an important part of my practice and I’ve always made time and many personal sacrifices for my patients. Recently, I met a young woman with breast cancer who planned to undergo bilateral mastectomy and together we planned an innovative type of staged breast reconstruction using de-epithelialized local flaps from her sagging breast together with acellular dermal matrix (ADM) allograft and tissue expanders. She was happy with my plan and confident in me. The problem here was that her insurance company waited till nearly the last minute to refuse certifying the use of the ADM as part of the surgery. In essence, they refused their client, my patient, state of the art and generally accepted standards as part of her surgery. This required that my office staff fight for my patients rights for the two days prior to her double mastectomy! Imagine the anger we had and disgust we had when the insurance company said that what we were planning to use was experimental.

Not only did they refuse to cover it as reimburseable but they threatened to not to cover the hospitals cost for the product therefore leaving the patient with a very large (significant) cost even as I considered waiving my fee for the ADM!

I blocked out the controversy as I concentrated on helping this young woman, but I felt so sorry for her that she had to deal with this nonsense in addition to her diagnosis of breast cancer and double mastectomy. She was so brave and calm through it all and we used the acellular dermal matrix as part of the original plan in spite of her insurance company, and I am happy to report it aided me in helping her achieve a great beginning outcome in breast reconstruction.

So, I ask you- people- are we just going to stand around and let insurance carriers dictate to us now not only whether they will cover procedures but how your surgeon should technically perform the very essence of surgery?!

This portends to bad things to come and forshadows a future where doctors are forced to acquiesce and do inferior work just to save the insurance company a buck. Disgusting ! Don’t stand for it people. That is why I am an out of network provider. I had the ability to refute what this insurance company tried to pull on our patient. I don’t know if an in network provider could have done the same without reprisal?

Speak out against this type of corporate micromanagement and allow your surgeon to be your advocate and make the medical decisions that are best for you.


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Graphite/Pencil Hybrid-Painting by Dr. Scott Spiro