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!

8 Comments

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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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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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.

2 Comments

I personally would go for two more consults!!

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Did they require you to be a certain weight and height to be covered by bcbs?
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