Disappointed with Consultation Today :-( - Philadelphia, PA

I am a 39-year-old mother of three and have had...

I am a 39-year-old mother of three and have had large breasts for as long as I can remember. I was hoping that after having children and nursing all three of them, that my breasts would shrink. Unfortunately, they did not....they only sag more than before!

I am a 38F and have been contemplating a breast reduction for a few years now. I finally had the courage to schedule a consultation with a local PS and went today to speak with him. I left feeling disappointed because he thinks I have about a 5% chance of getting insurance approval. I even had two letters of support (no pun intended!) from my physical therapist and my OB/GYN stating that a breast reduction would be extremely beneficial since PT/chiropractic/and massage therapies have not helped. Doctor said he would do the best he could, but thought he might only be able to remove 1-1.5 pounds and that might not be enough for insurance to approve the procedure. Has anyone else ever been denied by insurance and then appealed it? If you did appeal it, what information did you use? Thanks for any info you can provide!

Denied by Insurance

So I got my official letter today from my insurance company saying that they are denying the breast reduction because I am not having enough tissue removed. Doc says he could remove about 400 grams, but insurance says it should be 575 grams to qualify the surgery as being medically necessary and not just cosmetic.

I don't even know where to start now. Should I appeal? Are my breasts really an "ok" size? Starting to question my judgment at this point.

On the other hand, would insurance like to start paying for the special size bras that I would have to buy for the rest of my life? Would they also like to continue to pay for the PT, chiropractic care, and massages that are often the result of shoulder and neck pain?

I don't even know how to proceed with filing an appeal with insurance if I decide to go that route. Help! Any advice welcome.
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Comments (10)

I personally would go for two more consults!!

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Don't give up!!  Keep pushing and moving forward.  Many women have been turned down 2-3 times and then were finally able to get approval.

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Miracles happen...I was approved with no referral letters from primary or anybody. Just the photos from the plastic surgeon. I am a 38DDD and going to a C or D. I have Anthem BCBS. Good luck!
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Did they require you to be a certain weight and height to be covered by bcbs?
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Definitely appeal it, especially since physical therapy failed to address the pain. It's standard operating procedure for them and they may consider multiple requests as a legitimate medical need to address your pain, rather than just a cosmetic desire for better-looking breasts. And if you're not confident in your surgeon's commitment to getting this done for you because of the low tissue ammount to be removed, consider interviewing other surgeons. It's absolutely vital that you feel good about your surgeon and his commitment to relieving you of your pain. If he believes you have a true medical need, he should be willing to push back against the insurance company in order to address the pain and suffering of his patient, not be pushed around by them over an arbitrary number.
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P.S.: I have Blue Cross Blue Shield of Illinois, which I HIGHLY recommend. My surgeon, who was in our network, was a bonafide genius. Not only was my back, neck, shoulder and chest pain gone almost immediately, but my girls look better at age 52 than they EVER did at 22. Losing my grannyboobs literally took years off my appearance. I don't see anything wrong with that...pain free, pretty and perky?! What's not to love? I spend at least five minutes a day just lost in admiration at my gorgeous new girls. And I breezed through surgery and recovery. I'm only two months post-op, but I was back at the gym doing the Stairmaster and elliptical exactly two weeks to the day after my surgery, so no post-op weight gain. Whatever you do, don't give up. This is sooooooo worth it! I'd lived with the giant bowling balls on my chest for so long that I had forgotten what it was like to live pain free. Now I'm having to re-learn good posture and rediscovering how great it feels to sit up straight. As for your doctor, you should seriously think about getting a different surgeon. I can't possibly overstate how important it is for you to feel confident in your surgeon and his commitment to your well being. If you're disappointed about ANYTHING, he's not the one you need. You should be encouraged, not discouraged to be pain free. Sounds like he's treating you cosmetically, but never forget, YOU'RE the one living with the pain. If he's worried about how many cc's they'll pay for, he's not dealing with your pain...he's dealing with his own bottom line. So find a doctor who's into making you pain free before all other considerations. Your beautiful new breasts and all the pretty clothes you'll be able to wear afterwards is just a happy consequence of having finally done something about the backbreaking weight you've been lugging around all these years. Don't let anyone make you feel guilty for that. If they've never lived with the pain and yes, the embarrassment of oversized breasts, they can't relate. But if anyone should understand, it should be your surgeon. If relieving your suffering is not your doctor's first and only concern, then he shouldn't be allowed to operate on you. ABOUT THE SCARS: You're really not gonna care if the doctor has done his job properly. But if you go through with the surgery, once your incisions have completely closed, go to skinmedica .com and order the scar gel (but be sure to check with your doctor first). It's really pricey, about $90.00 a tube, but it's amazing how quickly it cleans up, flattens and fades your scars. Way better and faster than BioOil, Mederma and over-the-counter stuff. My doctor made me finish just one tube and then moved me to BioOil, and the results were mind blowing. Keep us posted on your progress. Good luck and see you on the other side of surgery!
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Thanks so much for your input...I may be looking into a second opinion. I was thinking that this was the guy since I had a referral to him from my OB/GYN.
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I was denied and my PS appealed and I was approved within a few days . But they stipulated that I was only approved me for the month of April . That gave me 2 weeks to prepare . But the good thing was I didn't have long to wait . I had a letter from my PCP and a letter from my orthopedic surgeon . She did surgery on my shoulder a couple of years back . It sounds like you may not have a caring PS to work on your behalf . My PS only took a little over a lb. and a half from each breast. I was a 40 G and now a 38 D . I wanted to be a C but he said with my body type they wouldn't be proportionate. I am very happy with my results at 30 days post op. I have Blue Shield of California . I have heard a lot of women talk about their insurance covering a certain amount being removed. I guess it depends on the type of ins. you have. Maybe you need to get a second opinion? Don't give up :-)
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Thanks glittergal! I have Personal Choice in PA so I guess I'll just have to wait and see. I asked the PS what cup size he would try to make me and he said he doesn't do it by cup size. He said his main goal was to relieve me of the pain and if he did that, then it would be a success. If, however, he was able to get me to a certain cup size, and had not relieved the pain, then he would have failed at doing what he does. Feeling slightly uncertain after that comment, although I do see his point. Besides, what man has ever worried about cup size?!?
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You should try Dr. Emily Pollard she's off of City Line Avenue, i just went and had a consultaion with her she was wonderful and my reduction was approved within days of my consultation. I have anthem bcbs PPO. You guy sounds really negative if you havent committed anything keep looking until you find a dr that you are comfortable with...it will work out!!
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