Naperville Woman's Insurance Denied Bilateral Mastectomy Morning of Surgery

Photo 1: Carmen Severino enjoys the shade outside. Photo 2: Carmen sings during a fundraiser held to raise money for her $5,000 insurance deductible.

Carmen Severino, 60, was diagnosed with breast cancer in February of 2015. She underwent chemotherapy and after much discussion with her doctor and other women, decided to go through with a bilateral mastectomy. Getting one breast removed wasn’t an option for her since she was afraid the cancer could come back in her other breast.

“I’m a performer, an entertainer, a public speaker and hopefully a soon-to-be-published author,” Severino said. “It’s important for me to be comfortable in my own body.”

On Aug. 5, Severino was scheduled to go into surgery at Edward Hospital in Naperville. The day of the surgery she found out coverage had been denied. Severino has coverage through Blue Cross Blue Shield of Illinois.

Severino’s doctors expected the surgery to be approved, so they went ahead with scheduling it.

“All the surgical nurses and the doctors that I’ve spoken to and the administration at the hospital have never had this happen before,” Severino said.

Severino said she spent hours on the phone talking with many different people looking for reasons as to why the coverage was denied.

“Everybody has a different reason and everybody has a different script they worked off of,” she said.

According to Severino, she was told it was denied because the hospital stay was too long. Another time she was told it was because BCBS didn’t want to do a bilateral mastectomy and would just take the diseased breast and leave the other one. She also had the option of having both breasts taken but no reconstructive surgery.

“Those are my options right now,” Severino said.

There was a silver lining for Severino, though. BCBS did approve a hospital stay.

As of now, Severino is left “twisting in the wind,” as she puts it. She has no date for surgery and is filled with worry and anxiety.

This is not the first time Blue Cross Blue Shield has denied someone near surgery. According to a Boston Globe article, Phuli Cohan was scheduled to have a double mastectomy, but on the eve of her surgery, she was denied coverage. Blue Cross Blue Shield of Massachusetts deemed the removal of Cohan’s non-cancerous breast medically unnecessary.

Mary Ann Schultz, senior manager for media relations and public affairs at Blue Cross Blue Shield, said women who have received a cancer diagnosis in one breast would need to meet the medical policy to have the non-cancerous breast removed also.

According to BCBS’s prophylactic mastectomy policy, to be eligible a patient would need to have a known BRCA1 or BRCA2 gene mutation, be at high-risk of having that gene mutation due a family member having it, have Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome or have a first-degree relative with one of those syndromes or a high risk of developing breast cancer defined by family history or the patient received radiation therapy to the chest between 10 and 30 years of age.

Despite the difficulty of having coverage denied, Severino said everyone she’s dealt with at BCBS has been understanding of her situation.

“They’ve understood my frustration and my tears and my fears,” she said. ”Many of them have family that have experienced breast cancer so they try to be nice.”

It’s the BCBS corporation Severino has an issue with, saying she’s not looking for a free boob job.

“I’ve already had chemotherapy, I’m already bald, I’ve already been sick, I’ve already been through all that stuff,” she said. ”I’m not playing a game here. I’m just trying to get my health so I don’t have to worry about it coming back.”

If Severino is found to have the BRCA1 or BRCA2 gene mutation that results in a higher chance of developing breast cancer, BCBS told her it would approve the surgery. Severino has not yet had the test to determine if she carries the genes.

Severino is still going through chemotherapy and would have continued until next year. But now that the surgery is off, she doesn’t know what the next step is.

“I don’t know what’s going to happen,” she said, fighting tears. ”I don’t want to have to worry anymore. Once you had breast cancer you don’t want to go through it again.”