Does Insurance Cover Prosthetics - Breast Prosthetic Coverage

A “clinical anaplastologist” is a board certified health care professional that creates a custom-designed, fabricated and fitted prosthesis or medical device that does not articulate and is non-weight bearing. Anaplastologists provide an aesthetic device custom designed to support, modify, replace, protect or restore some passive function to an anatomical structure.

Anaplastology patients have varying injuries, diseases, cancers or traumas that can result in a loss of an anatomical structure requiring replacement. These specialists work with other members of a rehabilitative health care team to help return their patients to a normal daily life by creating a life-like prosthesis that helps normalize the appearance of lost, missing, or damaged soft tissue. Competent analytical, clinical and technical skills are required to perform safe and effective patient care.

Certification in the field of anaplastology is provided by the Board for Certification in Clinical Anaplastology (BCCA). Professionals certified by the BCCA are designated as Certified Clinical Anaplastologists and denote their credential with the CCA title.

Services rendered in this office are considered reconstructive, hence, covered by most insurance companies (Medicare and Medicaid included). No one likes surprises when receiving a bill, so we do our best to ensure that you receive the maximum coverage when we obtain your pre-authorization. We do all the billing for you and will inform you prior to your appointment of any possible out-of-pocket costs. Your portion of the payment is due when services are rendered. We accept cash, checks, Visa, MasterCard, and Care Credit. Please note that preauthorization can take anywhere from several days, to possibly four weeks.

Just call our office at 303.973.8482. Be prepared to give us your insurance information as well as your doctor’s name and phone number. We will obtain a physician’s order, and then complete a pre-authorization before we schedule your appointment. Note: many insurance companies will not pay for services unless a pre-authorization is in place prior to your appointment.

Please note: Due to the structure of our office, breast cancer patients, eye polishings, and consultations can be seen fairly quickly; however, for everything else, the wait is longer. You are encouraged to keep us in the loop regarding your treatment so that we can minimize the wait time.

Written, detailed instructions are sent home with each individual patient. You can also view specific instructions online: Care for Breast Prosthesis, Care for Eye Prosthesis or Care for Silicone Prosthesis. Even though care should be simple, details are often forgotten. If you find you are spending a lot of time fussing with the care of your prosthesis, please call our office – we try to simplify your life through what we do here – not complicate it!

Skip the middle man and contact Factor II directly: 1.800.332.8688 or online at www.factor2.com.

Most external breast prostheses are filled with a whipped silicone or gel, and are encapsulated in a polyurethane skin. While the gel allows for some drape, it is typically heavy, hot, and fragile. The polyurethane does not breathe, and therefore, traps heat. It is also susceptible to damage. When this occurs, the gel can leak out of the prosthesis and will sometimes mold. Pocketed mastectomy bras are also required to wear such prostheses.

Both custom and non-custom prostheses offered by Prosthetic Illusions, while lighter in weight, are still properly weighted for balance. The outer skin is breathable, and the inside (and back) of the prosthesis is a silicone, sponge-like foam that is highly durable. If the prosthesis is torn, the overall integrity of prosthesis is not compromised and still very usable. It is not as hot, and can be used in a normal bra against your skin.

The most common complaints of gel-filled forms are: heat build-up, tearing/punctures/leaking, too heavy, skin irritations, permanent bubbling with altitude changes, breast forms noticeably “floating” upward while swimming, and the additional expense of needing specialty lingerie and mastectomy bras.

The Women’s Health and Cancer Rights Act of 1998 (WHCRA*) legally ensures that all women with private insurance, have benefits that will cover any reconstructive process necessary to make them feel whole again.

For many women, this means having reconstructive surgery, and for others, it means having a custom made (or non-custom) reconstructive breast prosthesis. Anecdotal reports indicate that women who do nothing have a more difficult time healing, and have more incidences of the cancer returning because of their poor psychological health.

Women’s Health and Cancer Rights Act of 1998, states “WHCRA requires group health plans and health insurance issuers to provide coverage for… – Prostheses and physical complications at all stages of a mastectomy, including lymphedemas. WHCRA requires coverage to be provided in a manner determined in consultation with the attending physician and the patient.”

*Medicare is exempt from WHCRA

Due to the nature and construction process of a prosthesis, we will do everything necessary to ensure the most comfortable fit possible. Every prosthesis is custom made to fit your unique design and need, therefore will be constructed and sized until it fits you properly.

Non-Custom Breast Forms Exchange Policy: The non-custom breast prosthesis is meant to create the general shape and contour of breast tissue and not be an exact replacement of the original breast. All size exchanges must be made within 5 business days of purchase/item procurement in order to receive size exchange. After 5 business days, no exchange is allowed. All products must be returned in the original condition including packaging, documentation, warranty cards, manuals and accessories. Shipping fees will not be reimbursed and all return shipping/postage costs are the responsibility of the patient. We are unable to accept returns on items that have been damaged, stained or altered from its original condition in any way.

Non-Custom Breast Form Warranty: The non-custom breast form is warranted to the original purchaser only, to be free of defects in materials and workmanship for two (2) years from the original date of sale to the original consumer purchaser. If defective, you must notify Prosthetic Illusions retailer promptly and in writing with a warranty claim in order to receive a replacement form. Return form in original box to your Prosthetic Illusions retailer with dated proof of purchase. Transportation, postage, and insurance charges are your responsibility. If this was an Internet sale, or if your retailer cannot be contacted, notification can be made through the website: www.prostheticillusions.com.

Excluded from this limited warranty are defects in the Prosthetic Illusions product that has been modified or altered. Specifically, but without limitation, attaching or applying to our product any material, object or product that was not manufactured by us will void this limited warranty. This warranty does not cover accidental damage, improper handling or repairs made by unauthorized persons, and specifically excludes claims for indirect, incidental, or consequential damages. Failure to act promptly will render this limited warranty void. Prosthetic Illusions is not responsible for damages resulting from mishandling and abuse in transit. If such damage occurs, you should file a claim with the carrier. This warranty gives you specific legal rights and you may have other rights, which may vary from state to state.

Have more questions? Please contact us at 303-973-8482 or info@prostheticillusions.com