Special Report: Local woman with family history of breast cancer denied preventative surgery by insurance company

Special Report: Woman denied insurance coverage to have medical procedure

EL PASO, Texas - Discovering a lump in your breast is one of the most frightening things that can happen to a woman. What would you do to prevent breast cancer?

Kelly Garland, a Hatch, New Mexico woman, wanted a double mastectomy. Her doctor agreed, her insurance company didn't.

"My sister passed away first. I was 22 and just getting ready to get married to my husband," said Garland, "My mother passed away eight months later."

For Garland, 37, the threat of breast cancer has been all too real. "That year was a really hard year for us."

One could imagine her reaction when, last March, she felt a lump in her breast. "Immediately, I thought, 'I want a mastectomy,'" said Garland.

Doctors said the lump was benign, but her physician agreed to perform a bilateral prophylactic mastectomy.

Garland, a registered nurse, took to documenting her preparation for her surgery in a blog. She was hoping to demonstrate her passion for patients to advocate for themselves and their health care decisions.

Then, bad news.

"He called me two days before the surgery was set to happen and he said they denied him," Garland recalled. Her insurance, Blue Cross Blue Shield of New Mexico, has a policy that requires any patient requesting a double mastectomy fit certain criteria.

Among that criteria: a history of cancer in one breast, a high genetic risk of developing certain cancers, and a confirmed family history of breast cancer in two relatives - either a mother or sister.

"It sounds like they're splitting hairs," said Garland, "to come up with a reason to not do the surgery."

The insurer sent ABC-7 a statement: "We make coverage decisions using evidence based medical policy and criteria. ... We encourage members to use the appeals process ... Their physician can speak with one of our medical directors if desired."

Garland says her appeals, and her doctor's, were denied. "God forbid if something happened and I did get cancer," Garland said, "Wouldn't it cost the insurance company more to treat that than to provide this?"

The National Cancer Institute doesn't believe a double mastectomy without cancer present is appropriate for women who aren't at the highest risk.

ABC-7 reached out to El Paso doctors not connected to Kelly's case for their expert medical insight.

Dr. Manuel Acosta, a general surgeon, told ABC-7 insurance companies won't cover the cost if their criteria is not met. "If she has enough money and she wants to go to a plastic surgeon, she will have to pay out of pocket."

"It definitely shouldn't be the insurance company that makes the choice on what the best treatment for the patient is," said Dr. Frank Agullo, a cosmetic surgeon who says he often battles insurers over reimbursement.

Both support Garland's decision. In the meantime, they ask she abide by medical recommendations: monitor and screen every six months.

Garland says she's frustrated about her situation, but she'll follow the orders. "Cancer is all around us and I was just looking for a way to ensure a decrease in my chances of getting it," Garland said, "I want to be around for my kids. I want to be around for my family."

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