Insurance Appeal- How Do I Ensure My Reduction Is Covered?

My insurance denied my breast reduction because my surgeon did not submit a specific number of grams to be removed. After examining me, she said she could remove the amt they suggested. They submitted an appeal, but my surgery date is fast approaching. I called my insurance co. and they tell me that all the criteria was previously met except the amt of tissue and because of that it is still in appeal. Is it safe to assume that the procedure will be covered if she removes the recommended amt?

Tags:

Comment on this

10 Doctor Answers | Asked by Ellie83 in State College, PA

Doctor Answers (10)
Community Comments (0)

Breast Reduction - Insurance Coverage

No, it is not safe to assume that. What is safe is to assume nothing. You should work quickly to coordinate the submissions of your plastic surgeon's office and your insurance company, and indicate to all involved that you will not proceed with the surgery on the currently scheduled date until everything has been okayed IN WRITING. Doing otherwise risks having your surgery not be "covered," and exposes you to significant charges after-the-fact. There is no... more

Breast Reduction-Insurance Appeal

I would recommend that you not have your surgery unless you get the approval, once the surgery is done it is much harder and you may end up having to pay out of pocket. If you have your insurance through employment, see if your HR department can help you expedite the process so you can keep your surgery date. Also, you should call them everyday, get the name of a contact person you can speak to each time who may help you! Good luck. see video

You can never guarantee an insurance company will pay for your surgery

I know of breast reduction cases where surgery was precertified by the insurance carrier, the patient achieved resolution of all symptoms, both the surgeon and patient were very pleased with the surgical result and the carrier paid for the surgery. Several months later, the carrier sent a letter of adverse decision and a demand for repayment because the minimum amount of tissue was not removed. I know of no way to accurately predict how much tissue will be removed during... more

Insurance Coverage for Breast Reduction

It would seem that if they told you that it should be covered if the required amount of tissue is removed you could go ahead. I would not believe anything unless it is in writing from an insurance company. If it is in an appeal, your best bet is to call and try to get an expedited review of your appeal since your surgical date is fast approaching. If you do not get a written authorization prior to your surgery, I would be hesitent to proceed until you do. Your doctor can try to contact your... more

Scott R. Brundage, M.D.

5 reviews

Grand Rapids Plastic Surgeon

Breast reduction

Insurance criteria for breast reduction is so variable and insurance companies are so capricious. Find out what there criteria are and if yoru surgeon gave an approximate # of gms for removal, then your should call yoru isnurance company yourself to push throught the approval.

Steven Wallach, MD

12 reviews

Manhattan Plastic Surgeon

Breast Reduction

I agree with Dr Gutowski below, not just because he is Polish, but because he has a good point. Insurance may cover breast reduction for some women. It depends on the patient’s breast size, body type, and symptoms. Most insurance companies have a formula based on your height, your weight, and how much your surgeon estimates will be removed. Usually removal of about a pound from each breast is required for insurance coverage. Health care providers are mercenary about... more

Insurance Coverage for Breast Reduction

In almost all insurance cases, a Prior Authorization does NOT guarantee that payment will be made. There is not way to know until after the surgery is done.

Breast reduction precertification

I would assume nothing. I will say, performing breast reductions on a weekly basis, I do not understand why your surgeon did not understand that a precert letter which does not contain gram weight would be automatically denied. Your physician's office should be handling this for you. If they do not, then there are many other plastic surgeons out there. It is always better to do it right the first time than to go through an appeals proceeding. The insurance company can delay approval for... more

Never assume breast reduction insurance coverage

We have found the the only assurance that breast reduction will be covered by your insurance plan is a full perdetermination, and confirmation of coverage in writing. Even with a written coverage agreement it is wise to keep all documents handy, and records of any one you spoke to at the company. The insurance company line has always been that a coverered benfit is not a guarantee of payment for services. Best of luck, peterejohnsonmd.com

Breast Reduction and Insurance Coverage?

Thank you for the question. One of the principles we follow in my office is that it is not “safe to assume” anything, especially when it comes to insurance companies. If you want peace of mind you will have to obtain something in writing from your insurance company stating that your procedure will be covered if a certain amount of breast tissue is removed. Best wishes for a successful procedure; breast reduction surgery is one of the most patient... more