Woman fights insurance on mastectomy

HATCH, N.M. (KRQE) – Finding a lump in your breast is one of the most frightening things that can happen to a woman.

So imagine how much more frightening it is when your mother died from breast cancer and your sister from ovarian cancer.

That’s the reality of a Hatch woman.

And while she has found what she believes is a solution – a double mastectomy – her insurance company isn’t on board. But she’s not going down without a fight.

“My sister passed away first. I was 22 and just getting ready to get married to my husband,” said Kelly Garland. “And my mother passed away eight months later. And it was three weeks before my son was born. I had high hopes that she would get to meet him. That year was a really hard year for us.”

In 37-year-old Garland’s family, the threat of breast cancer has been all too real, so imagine her reaction when, last March, she felt a lump in her breast.

“Immediately I thought, ‘I want a mastectomy,’ and ‘I don’t even want to play with it or deal with it,’ and I shouldn’t have to,” Garland said.

Doctors deemed it benign, but her physician agreed to perform a bilateral prophylactic mastectomy on Garland.

Then she got bad news.

“He called me Friday, two days before the surgery was set to happen and he said they denied him,” Garland said.

Her insurance company, Blue Cross Blue Shield of New Mexico, has a policy that requires any patient requesting a double mastectomy to fit certain criteria: That they’ve had a history of cancer in one breast, they’re at a high genetic risk of developing certain cancers, and a confirmed family history of breast cancer in two immediate family relatives.

“It sounds like they’re splitting hairs, to me, to come up with a reason to not do the surgery,” Kelly said.

The insurer declined a request for an interview, instead, sending a statement, which reads in part:

“We make coverage decisions using evidence-based medical policy and criteria. … We encourage members to use the appeals process … the member or their physician can submit additional information that may not have been available initially, and their physician can speak with one of our medical directors if desired. We are committed to getting to the right coverage decision.”

Garland says her appeals – and her doctor’s – were denied.

“If God forbid if something happened and I did get cancer, wouldn’t it cost the insurance company more to treat that than to provide this?” Garland said. “Am I really not considered a high-risk person?”

ABC-7 reached out to El Paso doctors not connected to Garland’s case for their expert medical insight on this situation.

Cosmetic surgeon Dr. Frank Agullo said, “It definitely shouldn’t be the insurance company that makes the choice on what the best treatment for the patient is.”

Agullo says he often battles insurers over reimbursement.

“That’s definitely not the way it should be. We want to avoid cancer,” he said.

Garland says she wants to be around for her kids and family.

“I’m only looking to try and make that happen,” she said.

She’ll try, she says, with or without the support of her insurance company.

Garland says while her doctor’s appeal to the insurance company has been denied, she is still working on her appeal.

Garland says while tests show that she does not carry the BRCA 1 gene that’s prompted many people like actress Angelina Jolie to have a double mastectomy, she says because her mother and sister were never tested, there is no way of knowing if their cancer was genetic.

According to the National Cancer Institute, The BRCA1 and BRCA2 genes only account for about 20 to 25 percent of hereditary breast cancers.

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