It had been a long four years since that July night when Marianne Sarcich first felt the lump in her right breast as she toweled off from the shower.
Breast cancer.
The cancer was caught early enough that it hadn’t spread to other parts of her body, but doctors said she would need a mastectomy to remove the breast and the cancer in it.
The implant he received after surgery developed scar tissue, became painful and eventually had to be removed.
This time, in 2020, Sarcich opted for a newer type of surgery, in which tissue from her left thigh was transplanted into her breast to form a breast.
She was finally starting to feel – and look – like herself again.
“After the mastectomy, I couldn’t look at my breasts for months, I tried to avoid mirrors. It took me so long to realize that it’s me,” said Sarcich, 55, of Wilmington.
Her relief was short-lived. The reconstructive surgery was covered by her health insurance, but she soon discovered that a follow-up procedure to thin her right thigh to match her left was not.
Having feet of the same size was considered cosmetic, not medically necessary.
Federal and state laws require that health insurance cover breast reconstruction after a mastectomy, as well as any subsequent procedures to restore symmetry between the breasts. However, patients often have difficulty getting insurance coverage for surgery to restore the appearance of other parts of their body when the tissue was harvested for reconstruction.
The process of appealing insurance denials can be daunting, especially for people who are physically and emotionally exhausted after cancer treatment and recovery. Those who cannot navigate the denial process may eventually go without follow-up care.
“At a time when a woman is literally fighting for her life with breast cancer treatments and a very disfiguring surgery, she shouldn’t have to fight her insurance company,” said Pat Halpin-Murphy, president of PA Breast Cancer Coalition. “It takes all her energy to heal.”
Breast reconstruction options
Many women who undergo a mastectomy for breast cancer treatment choose some form of reconstructive surgery. The choice of procedure is personal.
Implants filled with silicone gel or saline are among the most common options. “Flap” surgeries – when a patient’s own tissue is transplanted to form a breast – are popular among women concerned about the lifespan of synthetic implants, which often need to be replaced or augmented within 10 years, or who have health problems that put them at risk for greater complications with implants.
Flap procedures can take tissue from the stomach, back, or ribs. After problems with her implant, Sarcich underwent patent artery puncture (or PAP) flap surgery, in which tissue was taken from the upper back of her thigh. Although less common than other flap procedures, the PAP flap is an option for patients who do not have sufficient tissue in the abdomen, back, or other common donor sites.
In a surgery that lasted more than four hours, doctors cut from her left buttock to her inner thigh to remove a crescent of skin, tissue and part of the sheep’s artery, the thigh’s main blood supply. The surgeon transplanted the tissue into the breast, carefully connecting the blood vessels there to prevent the tissue from being rejected.
Patients stay in the hospital for about three days and take up to six weeks to recover.
Since the 1990s, federal law has mandated that health insurance cover reconstruction after breast cancer treatment. Pennsylvania in the late 1990s passed a law requiring insurance companies to also pay for surgery to restore symmetry between the breasts after reconstruction.
However, the law does not require insurers to pay for subsequent surgeries to restore the appearance of the donor area in flap patients.
“Insurance companies have basically used that wording to not offer coverage for the kind of things that Marianne needed,” said Liza Wu, Sarcich’s plastic surgeon at Penn Medicine. “It’s not necessarily a complication of mastectomy. It’s not a hole in the chest wall or a wound that won’t heal. It’s a result of the reconstruction and it’s not functional, it’s an aesthetic result and that’s where the gap comes in.”
Sarcich was stunned that her insurer, Independence Blue Cross, would deny coverage for the subsequent surgery, a thigh lift on the leg that had not been used in the reconstruction. And then he got angry. It hadn’t occurred to her that part of her recovery wouldn’t be covered by insurance.
The cash price for a thigh lift is between $1,400 and $2,000 — not including hospital fees — in the Philadelphia area, according to Fair Health Consumer, a searchable price transparency website.
“I was extremely disappointed that the insurance company stepped into my medical care in a way that I didn’t feel was appropriate,” she said.
Independence Blue Cross evaluates requests like Sarcich’s “based on the member’s contractual benefits and clinical data and circumstances,” Donna Farrell, senior vice president of corporate communications for Independence, said in a statement.
“The appeals process is intended to allow experts in the field to assess the case. Independence honors that decision, whether it’s the same decision as the original or overturning the original decision,” Farrell said.
Fighting insurance denials
Even when a procedure is approved, breast cancer patients often face challenges with copays and coinsurance, or find that a portion of their reconstruction was billed incorrectly.
“Reconstruction is not a single code and it’s not a process — even if it’s not a complex affair, there are always related services that could easily be dismissed,” said Beth Virnig, a professor of health policy and management at the University of Minnesota..
When insurers deny a procedure, trying to prove necessary care becomes the patient’s burden — and one that is too much for many to bear.
“There are a lot of times when women say enough is enough and they just stop — not because there aren’t people who couldn’t improve it, but because they get tired of fighting for safety,” Wernig said.
Sarcich poured her heart into a letter of appeal, explaining why the process was so important. She was denied again.
After a second insurance denial, patients can file another appeal — this time to an independent adjudicator. Insurers and patients are bound by any decision made by the independent adjudicator.
A former PR specialist, Sarcich used an old trick she used with clients: She tried to think like the insurance company. He picked through the denial letters to find the exact reasons they gave—that the procedure wasn’t medically necessary—and built a case to address those specific points.
First, Sarcich went to her physical therapist to find out if having two different-sized thighs could affect her physically, perhaps altering her balance or prolonging her recovery—unlikely, she was told.
So she went to her oncologist and social worker to ask if they thought the emotional distress she felt about her unbalanced appearance could be exacerbating her post-cancer anxiety. They agreed that she could and wrote letters to support her.
She also collected letters from her plastic surgeon and the Pennsylvania Breast Cancer Coalition. “The emotional toll was huge. My fear was that I wouldn’t win, but I will try as hard as I can,” said Sarcich. “I felt I was right. I didn’t think what I was asking was off base.”
Halpin-Murphy, who sponsored the Pennsylvania law requiring insurers to cover breast symmetry, says it doesn’t have to be complicated: Insurers should cover any surgery related to breast reconstruction to make patients feel as whole as possible.
“It’s hard enough, to have a mastectomy and then you have reconstruction and they take another part of your body … and then you have disfigurement in another area,” said Halpin-Murphy, who wrote a letter to support Sarcich’s case.
It’s an unsettling experience and feeling to have part of your body missing, and people shouldn’t be “reported” because they want any operation that will help them feel like themselves again, he said.
“I don’t think you should claim mental health,” Halpin-Murphy said. “I think it’s mentally healthy to want to do that.”
In February, the independent reviewer agreed that the procedure was necessary, and Sarcich had the follow-up surgery in April, as soon as her surgeon could fit her in.
She is progressing her recovery slowly, regaining her physical strength and confidence one day, one look at a time.
