This month, we offer an example of persistence by the patient and her family resulting in a reversal of coverage denial. Even the most reliable insurers make mistakes and need to be alerted to them. Insurance employees without the proper training and credentials may make inappropriate decisions regarding the coverage of medically necessary care.

You and your clinical team can help patients and their families recognize these situations and provide them with guidance to successfully overcome such barriers. Your ability to make a positive impact goes well beyond the provision of medical care.

Virginia, a 51-year-old law librarian, was married with three children in college when she was diagnosed with early stage breast cancer. Her oncologist initially believed she could be adequately treated with a lumpectomy. However, she had an extensive family history of breast cancer, and after being informed of this, her insurance carrier agreed to cover a bilateral mastectomy, followed by breast reconstruction with saline implants.

The reconstructive surgery was performed at Virginia's local community hospital by a surgeon with no training in this aspect of breast cancer follow-up care. The result was unsuccessful, leaving her with a misshapen and asymmetrical reconstruction. This surgeon eventually lost his license due to misrepresentations related to his medical training.

Devastated, Virginia opted for a second reconstructive surgery during which a plastic surgeon corrected the serious asymmetry created in the initial surgery. The surgeon replaced the saline implants with silicone implants. Virginia's insurer had approved all her cancer treatment and the initial reconstruction, but denied the secondary corrective surgery as "not intended to correct a functional problem" and therefore as being essentially "cosmetic."

Appeal Strategy

Virginia's oldest daughter, Alyssa, in her last year of college, had become a volunteer for a breast cancer support organization in her college community. The group provided support to her mom in pursuing her appeals within her insurer's appeals structure. When all of the internal appeals were exhausted, Alyssa contacted the Medical Care Ombudsman Volunteer Program (MCOP).

MCOP quickly assembled a panel consisting of medical oncologists, surgical oncologists, and plastic and reconstructive surgery experts. The panel was understandably shocked by the coverage denial of the secondary surgery given the patient's history.