I suggest getting documentation by your plastic surgeon, have him or her submit photo's and a request for authorization with procedure plan so it is documented pre-operatively. Judging from your picture I feel strongly your surgery will be covered. If in the unlikely event it is denied, your out of pocket costs for the surgery , anesthesia, and operating room would be $9,500.
You are correct, it can be confusing and intimidating trying to get pre-authorization for breast reduction surgery. Although, I am not an expert on negotiating the pre-authorization process; my business manager, Leann Clinton, is. You can call my office and ask my receptionist if she can put you in touch with Leann. Tell Leann, I responded to your question and asked that she help give you guidance. Best wishes, Dr. Lepore.
Hi there, great question!
It is unfortunate that we can’t get Medicare to pre-authorize
surgeries. However, if you see a board
certified plastic surgeon, her or his office staff should have people in place
who are experts at navigating the insurance companies. We often have a good idea on what Medicare
may or may not cover. I am always honest
with my patients if I feel they will not meet Medicare eligibility requirements
for any surgery. See your surgeon to get
the process started & good luck!Sincerely,Dr. Michelle Spring
You cannot get pre-authorization from Medicare for breast reduction. You only know if they will pay after you have submitted the claim. If they deny the claim you have to cover the entire expense. Therefore you have to follow the LCD, local coverage determination, criteria that Medicare requires for documentation BEFORE you have the surgery. There are specific criteria for coverage which include having certain symptoms like back or neck pain, skin problems and interference with activity. Others include evaluation by a doctor for endocrine abnormalities, and failed therapeutic attempts like physical therapy, support bras, etc. Your weight and body surface area and Schnur scores have to be calculated and the expected reduction in grams removed stated. All of this has to be documented in advance and submitted along with the claim. Also you can look up the coverage criteria in the medical necessity section f the website of your secondary blue cross/blue shield carrier.