Anyone Had Medicare Cover Cost of Surgery?

[MammaryMan]

I have very large, swollen, sensitive and often painful breasts that occasionally have a discharge.

The cause of the gynecomastia is the hormone blockade treatment I received for prostate cancer. I still take Avodart and Casodex. I have tried Arimidex and Femara to reduce the estrogen, but it had no effect on the breasts.

A local consulting plastic surgeon suggested that insurance should cover my case, but his office manager simply got the runaround from Medicare about "Local Coverage Determination" and prior approvals by being sent from one sub-agency to another in a circular fashion.

I have supporting documentation from my oncologist and a local family physician about my long standing condition.

I certainly meet the guidelines for medical necessity for surgery as outlined by organizations such as MassHealth and others.

If anyone has been a patient of a surgeon who has been able to wade through the Byzantine structure of Medicare to get the procedure covered, would you please post it.

I live in Colorado and would travel to have it done.

Thanks.

[Alchemist]

Hi Mammaryman,

I sympathize about the runaround.  I consult in the group health care business.  Good luck.  You will need it. I wrote computer programs that enforce the rules.  The trick is to have it absolutely "medically necessary".  Somewhere, something is going wrong. Sometimes it just matters who you talk to.  One day you may get lucky and get somebody who has done it before and says "I know how to do that".

[hammer]

We had 1 poster some time back last year that posted Medicare covered his surgery! He stated that he was on disability and the it was covered. I asked for more detail not for me even though I'm on disability and Medicare, but for others that may need to know. He never posted again as far as I know.

I believe the headline of his post was "my surgery covered by Medicare" or"Medicare covered my surgery" something along those lines if you want to lock for the post.

Good luck,

Bob

[Paa_Paw]

I don't think that was Medicare, but Medicaid. Medicaid coverage varies from state to state.

The last I heard, Medicare would not cover cosmetic surgery except to remove a cancer or for some kind of pathology. They will cover reconstructive surgery in some cases though.

[hammer]

That sounds more like the Medicare.