When Pearl Schainker of Chevy Chase opted against breast reconstruction after a double mastectomy 21/2 years ago, she said, "I was feeling very self-conscious about walking around that way." The breast forms she later bought to counter that feeling cost about $600, she said, a bill that her Mamsi insurance plan helped cover.
Schainker said she now needs to replace these prostheses, so she recently contacted her new insurer, CareFirst BlueCross BlueShield, to find out which retailers belong to its network of providers. In a letter to CareFirst, Schainker said she was first told there were no such providers in her area; then she was referred to three approved vendors. "The first . . . informed me that they only make orthotics for shoes," she wrote. "The second . . . phone number I called had been disconnected. The third vendor required three separate phone calls to determine that they did not carry mastectomy prosthetics."
Further calls to CareFirst, Schainker said in her letter, produced a list of out-of-network vendors and instructions that "it was up to me to call them, ask if they carried post-mastectomy prosthetics, and determine whether they are in a 30-mile radius of my home."
"I knew it was a wild goose chase," she said, but "I called about eight or 10" of the businesses and found none that carried the items she needed.
"If I was doing this for the first time I would be hysterical, and I think most women would," said Schainker.
Two weeks after her letter -- "I feel that your company is avoiding responsibility and, in effect, forcing me to go out of network, thus enabling CareFirst to pay less in reimbursement," she wrote -- the insurer apologized for the inconvenience, told her to make the purchase wherever she chose and advised her to send her claim to an "executive specialist" for processing.
"The runaround that I got at first is probably what most everyone gets," said Schainker. "I find it pretty outrageous."
CareFirst officials did not reply to questions about the steps that other women should take to obtain coverage for breast prostheses.
The period after a mastectomy "is no time to be negotiating" for insurance coverage, said Sonia Nieves, cancer control manager for the regional office of the American Cancer Society (ACS). With many women receiving radiation or chemotherapy after surgery, she said, "this is a really hard time for them."
"We provide a bra and a prosthesis" free to mastectomy patients "until they really can move ahead" with reconstructive surgery or long-term prostheses, said Nieves. So far this year, she said, the ACS "Reach to Recovery" program has helped more than 600 women in the Washington area. "Most of them, they don't have insurance, or they have very low coverage," she said, and they tell her, " 'We didn't know how expensive cancer is.' "
-- Tom Graham
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