CEDARBURG — After her second breast cancer diagnosis, Judy Weiss, of Cedarburg, and her doctor decided a double mastectomy would be the best path to take.
But her insurance, WEA Trust, doesn't agree. WEA Trust will cover the removal of her right breast that has cancer, but not the left breast that's cancer-free.
"There's been a lot of tears and in fact, they might start now," Judy Weiss said in a video interview with the I-Team's Kristin Byrne.
Weiss, a high-school science teacher, beat breast cancer more than a decade ago. Back then, it was in her left breast and she had a lumpectomy.
Cancer came back this past summer in her right. It was classified as stage 3B breast cancer.
"It had metastasized beyond my breast into the lymph nodes of my armpit and further along into a lymph node on my collarbone," she said.
"My surgeon and I agreed that the double mastectomy was the best way to go," Weiss said.
Before surgery, Weiss learned WEA Trust wouldn't cover the cost of removing the non-cancerous breast. She decided to go forward with it anyway, borrowing around $15,000 from her brother to pre-pay for some of the medical care.
WEA Trust explained the denial in a letter sent to Weiss, citing the NCCN guideline.
"It didn't even apply to me because it referenced younger women and I'm 61," Weiss said.
Weiss is fighting the denial. She has relied on family to get through it all.
"Thanks to my siblings who have stepped in brothers and sister, to help me write these letters, and meet on conference calls with people, a lot of emotional and intellectual support -- otherwise I'm not sure I could have done it," Weiss said.
Her entire medical team of doctors has written letters to WEA Trust supporting her surgery.
In a letter, her oncologist said... "given her previously treated left breast cancer, as well as to provide her with a symmetrical postoperative result and to further reduce her risk of developing cancer in the future, a left simple mastectomy is also recommended..."
WEA Trust declined the I-Team's request for a virtual interview. A spokesperson provided the below statement:
"Payment for services is based on medical necessity and WEA Trust uses nationally recognized clinical guidelines to determine medical necessity in situations like this. We cannot publicly speak on a specific member, their claims, or health condition. We encourage all members to follow our Grievance Process if they have any concerns."
Board-certified patient advocate, Debbie Deutsch isn't connected with Weiss' case but looked it over at our request. She agrees with Weiss -- the health guidelines her insurance is citing, don't apply.
"It makes no sense. It doesn't make any sense," said Deutsch.
"WEA picked evidence-based points that Judith does not fit the criteria for," Deutsch with Patient Care Partners LLC said.
Deutsch points out, it would be cost-beneficial for WEA Trust to cover Weiss' double mastectomy.
"If they would approve what she is requesting it would be less expensive for the insurance company because there would be no need for future mammograms, there would be no risk for future breast cancer diagnosis," Deutsch said.
Deutsch applauds how Weiss has advocated for herself and thinks she should now get her local lawmakers involved.
Weiss says the fight at this point isn't just for her.
"It's really quite scary," Weiss said.
"I can imagine there are women out there going through this, who say, 'I can't do this surgery!'' Weiss continued.
Weiss has had a peer-to-peer review where her oncologist had a conversation with a physician affiliated with WEA Trust. That did not reverse WEA Trust's position on coverage.
She has also filed a complaint with The Office of the Commissioner of Insurance. OCI responded Thursday to her complaint, writing, "...our office is not able to pursue this as a violated of Wisconsin insurance laws."
Weiss says the medical bills for her surgery keep coming and she still owes her brother a large amount of money.
No matter what, she feels she decided to prevent breast cancer from coming back. She just wants her insurance company to see it the same way.
The I-Team reached out to Aurora, Weiss's medical provider to see if the hospital group would comment on this case. A spokesperson provided the below statement:
"While we cannot comment on the specifics of any patient's care or billing, it is our practice to work with patients in an attempt to resolve their concerns."