Hi FringeFemale,

I'm so sorry to hear all that you have been through!  

Somehow we get through it all and what doesn't kill us makes us stronger or so they say.   I believe that it has helped me in one way or another although it was one rough ride and still is at certain times.
There is life after explant and it can be a good one.   The studies say that women who have the explant done (en bloc) where they remove the whole unit capsule and all at the same time have a chance to regain their health and eliminate any chance of bad health for the future.

I'm at a loss right now to tell you how to fight the insurance company--- there must be a way with proven rupture!
We have some doctors on our list that know the right codes to use and so on and possibly we can get you pointed in that direction so you would just need to come up with travel expenses to have the surgery done.

I also have this saved from many years ago and it may be of some help to you now--especially since you know legal terms and so on.

   I know it's scary to live with the ruptured implants but you do have some time to work with--- it sounds like your doctor gave you some good advice on how not to activate further spillage.     I do know the type of implant you have-- or think I do.
The inner shell is full of silicone and the outer is saline.   The rupture of silicone should go into the saline.  If that happens, it should give you a little more time to work with.  You do not want to have that outer shell rupture tho.   
One step at a time!   You can do this.....
    Take some time to browse around the forum and read the different stories and also the articles in the Library.
Be sure to read about both silicone and saline since you have both!
We are here for you--- hopefully, someone else will come along to offer support and guidance as well.

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@aol.com.
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