Re: Beginning to navigate insurance -- sking for tips

[Guest guest]

Dawn,

We've had our reservations about Dr. Melmed. He's very personable, everyone likes him. But he doesn't take the fungal issue seriously and feels that it's safe to leave more capsule behind than the other doctors do.

As to insurance, read your policy. If it exempts all complications from cosmetic surgery, it's very doubtful you'll be covered. If you have contracture, or can show (they'll have the records) that you've been sick with chronic problems, you'll likely get covered. The codes the plastic surgeon uses have everything to do with that. . . A mastopexy is never covered.

As to all the papers you've gathered, IMHO, you can keep them for your own records. The doctors don't want to see the evidence! . . . They're still invested in placing implants . . . All you are asking is that the doctor remove them they way YOU want, and that the doctors skills are up to doing the job right.

In Shari's case, her insurance initially denied coverage. However, after they saw Dr. Blais' report, they relented. If I remember right, Shari had about 22 organisms growing in her implants and capsules.

I'd find another PCP though!

Hugs and prayers,

Rogene

[Guest guest]

Dawn

I paid for my explant as I didn't want to wait but after several appeals I won w/ my hmo - united healthcare at the time and was paid back. I sent them a ton of medical data which didn't really seem to help then after removal, Dr, Bridge noted that both implants were leaking and had less fluid then they were supposed to - one had mold and tissue growth in the valve holding it partially open.....the grosser looking of the two. He wrote my ins a letter saying what he noticed at that this could very well be the cause of my medical issues. then I sent them off to Canada to have them analyzed and after Dr. Blais' long repost on how nasty they really were, I showed Dr. Bridge the report upon a re-check and he wrote them another note for me.... this one won the appeal and I received all my money back less my co-pays, etc..... took months to get but I was adamant and it was worth it. Not all Dr.s will do this and I am not sure if he still does but it helped me tremendously... I received all but a few hundred back right before Christmas!!

hope this helps

shari

[Guest guest]

Hi Dawn

I had my implants removed last week and my insurance company (HIP)

covered it. It took about 4 months to get through the process of

seeing doctors and getting mammograms, then an MRI, needle biopsy etc,

but I stayed within the insurance network.

My understanding was that insurance would pay if you have Baker IV

contracture and that mamograms would be unable to detect breast cancer

because of the implants.

I wasn't sick otherwise.

If enough women stand up to these insurance companies and make them

cover explantation maybe more of the truth about complications due to

implants would start getting out to women who are considering getting

them.

I cut and pasted the following paragraph about getting insurance to

pay for it. I found this at www.siliconesurvivors.net/aware6.html

I hope it helps you...

" DON'T CALL YOUR INSURANCE COMPANY DIRECTLY TO ASK IF THEY WILL COVER

THE COST OF EXPLANTATION!! Two doctors must write letters stating that

it is a medical necessity that these implants be removed because of

(list symptoms and abnormal test results). Have the plastic surgeon

forward these letters to the insurance company. If they refuse to pay,

appeal the decision. If you have exhausted the appeals procedure, file

a complaint to the state insurance commissioner. If that fails, hire

an attorney to write them a letter threatening to sue them for failure

to cover this necessary procedure. Several lawsuits have succeeded in

forcing insurance companies to pay, so precedent has been set. "

>

> Hi womens,

>

> I was all set to go up to Dr. Melmed, but Shari opened my mind a

> little and helped me to consider staying close to home, by

> recommending her surgeon here in FL. Well, I did research yesterday

> and found a doc on the explantation.com list, who is about an hour

> away from me ( instead of 20 hours, like Dr. Melmed). He does en

> bloc, and he's on my insurance plan.

> Dr. Vinas --

> His bio says this he has " ...specialized training in Breast Care as

> well as cosmetic procedures such as midface suture suspensions,

> limited scar vertical breast reductions, vertical breast lift with

> internal suspension.... "

>

>

> Here's my question: Anyone with saline implants actually get an HMO

> to cover explantation costs? What are the steps I should take?

> I got bloodwork done ANA, RA, sed rate, but am waiting for results.

>

> Should I collect my records of the past year -- three visits to

> cardiologist, three visits to urgent care with chest pain ( thought it

> was heart attack), + regular visits to my primary care( for " anxiety "

> joint pain, etc)

>

> Who would I give that all to?

>

> Do people actually get coverage before surgery, or submit and contest

> it afterwards, once the implants were found to be faulty?

> What happens if the implants come back " clean " -- is it possible to

> prove the silicone shell was messing me up?

>

> Would I be nuts to go in to the doc with a pile of papers citing

> studies and such. I tried that with my PCP with the joint pain and he

> frankly said, " I don't believe you. " Didn't even take the stuff I

> brought him.

>

> What to do now? I'm kind of attached to Dr. Melmed, but I owe it to

> my family to go through insurance if I can. We have five kids.

>

> Dawn

>

[Guest guest]

---YES!! That sounds so encouraging, Dawn. Thanks for the message.

Love,

Sunny

In , halvey70@... wrote:

>

> Dawn

>

> I paid for my explant as I didn't want to wait but after several

appeals I

> won w/ my hmo - united healthcare at the time and was paid back. I

sent them

> a ton of medical data which didn't really seem to help then after

removal,

> Dr, Bridge noted that both implants were leaking and had less fluid

then they

> were supposed to - one had mold and tissue growth in the valve

holding it

> partially open.....the grosser looking of the two. He wrote my ins

a letter

> saying what he noticed at that this could very well be the cause of

my medical

> issues. then I sent them off to Canada to have them analyzed and

after Dr.

> Blais' long repost on how nasty they really were, I showed Dr.

Bridge the report

> upon a re-check and he wrote them another note for me.... this

one won the

> appeal and I received all my money back less my co-pays, etc.....

took months

> to get but I was adamant and it was worth it. Not all Dr.s will

do this and

> I am not sure if he still does but it helped me tremendously... I

received

> all but a few hundred back right before Christmas!!

>

> hope this helps

>

> shari

>