Bilateral Fitting With Significant Asymmetry and a Large Cup
A 64-year-old woman had bilateral mastectomies 14 months ago, with no reconstruction. Her right chest wall is flat with a well-healed horizontal scar; her left chest wall has a concave area near the sternum and a prominent ridge along the lateral chest wall. She previously wore a 42DD bra and reports that off-the-shelf pocketed bras gap at the top and dig into the lateral ridge. She has mild scoliosis and notices shoulder fatigue by mid-afternoon. She wants a natural silhouette under knit tops and is willing to consider custom prostheses if needed. She has Medicare and supplemental insurance and asks whether custom forms are covered.
1. What assessment steps and product options would you use to address the concave sternal area, the lateral ridge, and her shoulder fatigue?
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Assess both chest walls separately, noting contour, scar location, tissue mobility, and the position of the lateral ridge relative to the bra band. Because the sides differ, choose prostheses independently rather than matching a single size. For the concave sternal area, a form with a softer, tapered medial edge or a partial form may fill the hollow without creating a hard edge. For the lateral ridge, select a bra with a wider, smoother side panel and avoid rigid boning or seams that press on the ridge; a soft, seamless pocketed bra in the correct band size reduces digging. Shoulder fatigue with scoliosis suggests weight distribution matters: consider lighter forms, wide cushioned straps, and a band that carries more of the load. Custom prostheses may be justified when standard forms cannot match the contour, but document the specific fit failure that supports the request.
2. How would you approach the coverage question and what documentation would you prepare?
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Explain that coverage depends on the plan and medical necessity criteria, and that custom prostheses typically require documentation of why standard options fail. Prepare a letter of medical necessity describing the concave sternal defect, the lateral ridge, the failed off-the-shelf trials, and the functional impact such as shoulder fatigue and skin irritation. Include measurements, dates of fitting attempts, and the specific product requested. Verify the supplier's Medicare enrollment and billing requirements, and confirm whether a physician order and detailed written order are needed. Keep copies of all documentation and note the patient's financial responsibility estimate. Avoid promising coverage; instead, describe the process and timeline so she can plan.