Insurance Denied My Operation- What Can I Do?

I was denied from my insurance because they do not agree with my doc who wants to remove 700g from each of my breasts. They said according to the schnur's criteria. It states it should be 1070 removed. Am I to fat and need to lose weight to get this approved? What so I have to do to get this approved. I have severe neck and back pain that i have suffered for years. With other issures. Im 44 years old and wieght 241 lbs and is 5feet 10 inches tall.

Doctor Answers (4)

Insurance denial for Breast Reduction Surgery

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Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance.  I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well).  Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the large breasts. Supporting documentation is usually very helpful.  If you were denied, you can appeal and see if they will reconsider.  If you try all avenues and the insurance still does not pay for it, you may need to consider paying for it yourself to help alleviate your neck, back and shoulder pain.  My breast reduction patients are one of the happiest patients I have.


San Diego Plastic Surgeon
5.0 out of 5 stars 716 reviews

Insurance appeal for denied breast reduction

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If you are denied for breast reduction, there is an appeal process you can file with your carrier. Your doctors estimate is only that, and Schnur's criteria are dated and are a single opinion of modest medical evidence which are used to support insurance denials. If you are in a large work place or a union, also contact your benefits administrator to call on your behalf.

Best of luck,

peterejohnsonmd

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 28 reviews

You can appeal your insurance company or complain to the board of insurance

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Sorry to hear that your insurance company has denied your coverage for breast reduction.  It seems like you are a good candidate for the procedure and would benefit alot from it.  Having been denied coverage for your surgery, you can appeal the decision, you can complain to the state board of insurance, or you can pay for the procedure yourself.  Good luck.

James Tang, MD
Houston Plastic Surgeon
3.5 out of 5 stars 7 reviews

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Insurance Denied My Operation- What Can I Do?

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Regarding: " I was denied from my insurance because they do not agree with my doc who wants to remove 700g from each of my breasts. They said according to the schnur's criteria. It states it should be 1070 removed. Am I to fat and need to lose weight to get this approved? What so I have to do to get this approved. I have severe neck and back pain that i have suffered for years. With other issures. Im 44 years old and wieght 241 lbs and is 5feet 10 inches tall."

When you or your employer signed up with that insurance you company in effect you agreed to pay them a certain amount of money in exchange for them paying doctors and hospitals a certain amount of money for the care they will permit under certain circumstances. If under their interpretation you must have 1,070 grams removed per breast, to be paid your surgeon must follow this directive. If you do not like it, you can appeal (but in most cases such an appeal will be denied), switch insurance plans (in which case you may have to wait a year to qualify and find out that they may want the surgeon to remove as much or more), pay for the surgery out of pocket (which will allow you and the surgeon to decide how much should be taken off) or loose a serious amount of weight (which would reduce your estimated body surface area and the amount of needed breast tissue removal).

Good Luck.

Peter A Aldea, MD

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 60 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.