Insurance assistance

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TURNED DOWN BY INSURANCE FOR EXPLANT?

READ ON FOR THE GOOD NEWS! A Florida woman wants to help you collect or win preapproval from

AETNA/U. S. HEALTHCARE/UNITEDhealthcare/ METRAHEALTH (latter three after

7-19-96 to date) or any insurance carrier, for your explant with total

capsulectomy! In the past 2 1/2 years, since one member won against

Nationwide at trial and several others have filed suit against their

insurance companies, obtaining coverage for explant/ capsulectomy has

become common instead of the prior practice of denying most. The

circumstances for payment are still too limited.

Coverage is normally granted for Baker IV Contractures (hardened

with breast pain) for augmentation and Baker III Contractures, for

reconstruction, particularly for the later if the breasts look deformed

with breast pain. Also, rupture (silicone-gel only), breast cancer,

extruding or coming through the skin, recurrent breast infections, an

opening which has not healed exposing the implant or continu-ous drainage

(not minor!) in the area of the implant for, i. e. six months, even if

there is no evidence of an infection.

If your capsules/implants are calcified, this should also be

mentioned in your Office Notes by your Plastic Surgeon (P/S). The medical

literature reports 100% of calcified implants also have Baker IV

Contractures. This occurs normally in implants 15 years or older. If you

have calcifications, it should be noted on your mammogram report by the

radiologist and might show up on a chest x-ray.

The FDA says, ìIf a gel-gilled implant has ruptured, it should be

removed. Signs and symptoms of a rupture may include breast pain, tingling,

numbness, burning, changes in breast size or shape and changes in

sensation.î Often a woman with a rupture will complain of a burning acid

pain in her breast(s) and/or immediate area. If you are experiencing any of

these symptoms, tell every doctor you see and be sure they note it in your

medical records!

The P/S should state you had a ìruptureî in your operative report;

not a ìtearî or the implant was ìdisintegrated.î Also, the radiologist who

reads a MRI/ultrasound beforehand should say like, if so, ìThere is a 60%

to 70% chance the right implant is ruptured,î not ìpossible ruptureî which

will probably result in a turn down.

A P/S, who must generally make the request for preapproval or

reimbursement for you, might call the radiologist to ask him to amend his

report and to use termin-ology similar to mentioned here, if he has said

only ìpossible rupture.î Simpler

yet might be to contact your support group leader for her suggestion of a

radiologist and Plastic Surgeon first! If you do not know the support group

leader in your area or state, look at support groups under

http://www.trimaris.com/~ussw/ if you have access to the Internet.

If you are seeing a P/S to discuss explant, show him this brochure.

The insurance companies have kept them in the dark like they have us. The

P/S might fail to enumerate possible problems, such as described here, in

your Office Notes

(medical records) or not use the ìmagic wordsî such as Baker III or IV,

whoever is reviewing your request recognize from the guidelines.

Another possible reason for approval is a family history of breast

cancer (grandmother, mother, aunt and/or sister), since the implants often

obscure 30% to 50% of the breast tissue during a mammogram. Also, at times,

Atypical Chest Pain, with no underlying heart problem found after thousands

has been spent by your insurance company. Chest wall pain so severe it

mimics a heart attack, occurs in 12.6% of breast implant patients sooner or

later (Southern Medical Assoc., 1996). Submit your medical records and

bills showing the expense of all the tests done to rule out a heart attack

and have the P/S attach them, along with his Office Notes, hopefully, that

state this tends to reoccur but usually does not once explant takes place,

with your request. Recently, 16 articles documenting this condition have

appeared in the medical literature.

Hopefully, by setting a precedent with my case, the internal

guidlelines will be changed so that implants that are silicone-gel and more

than 8 years old to have coverage automatically granted, since the rupture

rate accelerates as the implants age. Your P/S needs to place in the Office

Notes how old your implants are and the probability of a rupture now

documented by the medical literature for their age and from his clinical

experience giving the approx. no. of breast implants he has removed. It is

widely accepted for gel-filled implants, approxi. 20% have one or both

ruptured or severely leaking (silicone-gel will extend 12 inches) at eight

years of age, 50% at 12, 70% at 14 and 95% at 20 years.

Your Plastic Surgeon or support group leader should be able to

supply you with an article in the July, 1997 Plastic Surgery Journal, pages

281-283, on 1652 explant-ed breast implants and summarizing the medical

literature thus far which conclusively documents the above statistics which

are probably on the conservative side.

Unfortunately, Champus will not pay for explant if done for

augmentation. They will if done for reconstruction, and you fit the

guidelines already discussed. However, if it is your 4 or 5th set of

replacements, they might refuse saying, ìYou should have figured out it

would not work on you.î I cannot imagine a woman undergoing surgery and

having replacements unless her doctor has given her assurance there is a

high degree of probability of it ìworking!î Contact your senators and

representatives to change these policies by Champus.

Also, those who are active military or their spouse is, if you fit

the guidelines as enumerated, they may have a P/S consultant perform the

explant at their facility or send you to a nearby one where there is a P/S.

Be sure the P/S removes the implants ìen bloc,î if at all possible, and a

total capsulectomy also! ìEn blocî means the capsule and implant are

removed as one unit so, hopefully, the capsule will hold any rupture

together preventing a silicone or contaminated saline spill into your

tissue. The majority of P/Sí, who have a minimum of 5 years of surgical

training and experience, are capable of doing this.

If you presently have or had explanted after April 1, 1994, at least

one Baxter (Hyer-Schulte), Bristol-Myers (Surgitek) or 3M implant, there

are 100 major insurance companies that the manufacturers reimbursed for our

care so they

will not ask you to assign the $3,000 explant benefit and/or ask you to

pay it back from your settlement. A list of these companies is at the back

of the Question & Answer booklet which came with the Notice of Status. The

list includes only commercial insurance carriers and not Medicare, Medicaid

and/or Champus.

Any settlement from Dow Corning is probably a few years away as the

present offer leaving Dow Chemical off the hook is unacceptable. Dow

Corning ìorphansî might be asked to sign an agreement to pay their

insurance carrier back out of any ultimate settlement. Hopefully, they will

eventually make similar arrangements with the major insurance companies

that Baxter, Bristol-Myers and 3M did so that repayment is not required.

That is at this point is only a hope!

Barbara Stock, who is suing AETNA for failure to pay for her

explant, needs your help. She has won round one; AETNA has admitted in

court filings they should have paid for her explant. She has added ìBAD

FAITHî meaning AETNA has done this negligently not only to her but others.

She needs to find other women who have been denied coverage by AETNA since

June, 1992 to date and by U. S. HEALTH-CARE, UNITEDhealthcare, and

METRAHEALTH after 7-19-97 when they merged with AETNA. PLEASE have anyone

turned down by the companies mentioned during the time periods enumerated

contact BARBARA STOCK, 415 Kilshore Lane, Winter Park, FL 32789, E-Mail

brstock@....

Those implanted after June 3, 1993 will have a difficult time. After

that date, you supposedly had full disclosure and access, if you spent the

time and effort, to adequate information about the possible complications.

If you have problems, the insurance companies feel you accepted

responsibility for them when implanted. Also, my attorney says until we

start consistently winning in court breast implants/ silicone causes

sytemic disease, we cannot expect insurance approval for this.

Unfortunately, the best of our attorneys lose 9 out 10 times on this point

at trial.

Anyone who has a policy which has a clause that anything in

regard breast implants is not covered; I believe these are unenforceable

for those implanted prior to 6-3-93. You should file a complaint with your

stateís insurance department who usually approved the policy in the first

place. Send along with your complaint a copy of this brochure and the

disclosure statements by Dow Corning, which up to 1985, gave us & our

doctors little information about possible complications. Their 1985

disclosures gave limited warnings. By then, breast implants had been used

for 23 years. These documents can be obtained from the Web Site address

already given.

If your coverage was obtained through your employer, your

spouseís or is in the time period of COBRA (18 months normally or 29

months, if you are applying for Social Security Disability/SSI), it is

governed by Federal law (ERISA). If you win, Federal Courts frequently do

not award fair attorneyís fees and for this reason, most will not handle

your case for denied health insurance claims unless you pay for the work.

This can be prohibitedly expensive!

You might be able to find an attorney who will handle your claim

for denied long-term disability benefits for a percentage of the

retroactive benefits eventually paid even though covered by ERISA. If you

live near a Federal Courthouse, visit and have them bring the cases up

under the name of your insurance company to see what attorneys are

representing the Plaintiffs (policy holders).

An individual policy, one converted after COBRA runs out and

sometimes for those who are self-employed with no employees (even though

technically a group plan), is filed in state court. Most statesí have a

long history for awarding fair attorneyís fees. The good point is, if you

win, since the insurance company has to pay your attorney, you keep the

entire award except for possibly punitive damages. The bad point is the

vast majority of attorneys who specialize in insurance will only handle

those described, since they need to be assured they will ultimately be paid

for their time, if you win.

If you have an individual policy as described and are denied

coverage for explant or other medical care, call LOUIS SILBER or CASS

CHRISTIANSON, 1-561-659-3300, the absolute best. They are my attorneys. If

they accept your case, there are no charges for their services.

For those without any resources or insurance to pay for explant or

insurance refuses to pay & you have no other resources (include spouse's

resources & income), send me a SASE No. 10 (4 1/4" X 9 1/2") w/55 cents in

postage & $2 only to cover the cost of copies for full info on an agency in

all 50 states that is federally funded that promptly paid for explant for 6

or 7 ladies in my support group. This is not Medicaid/Medically Needy Program.

Also, check with your support group leader; often a P/S will have a

special price for those in need. One in Orlando, FL has a package for

$3,585 for his fee, the same day surgical center & anesthesiologist. He is

a sweetheart, experienced at explant & does it "en bloc," if at all

possible. For those opting out, he and another P/S' in Florida will take a

Letter of Protection for their fee although you have to come up with

approx. $1,000 for other costs. Dozens of other P/S' will work with you

nationwide; talk to your areas support group leader to see if one is near

you. Where there is a will, there is a way to be explanted!

The opinions expressed here are solely of the author, Barbara Stock.

If medical or legal advice is needed, please consult a professional. This

write is strictly for educational purposes and is not meant as a substitute

for professional advice. The information contained in this write-up is

believed to be obtained from reliable sources but the author makes no

guarantees as to the accuracy.