I Was Recently Denied For A Breast Reduction Through BCBS. I Am Appealing, But Am I Wasting My Time?

It sounds like you are an appropriate candidate for insurance to cover your surgery.  Be aware that one of the ways insurance companies make money is by denying coverage the first time you ask, hoping you will simply give up and go away. Ask for your case to be appealed with a board certified plastic surgeon evaluating your case and photos. If you persist, you will probably be successful in getting authorization.

BCBS and other insurance companies use a scale based on body surface area to determine the amount of breast tissue removed.  Based on your height and weight, 500 grams need removal.  Unfortunately, you cannot reason with them if that's the amount they require.  If you have a breast reduction with less than 500 grams removed, they may or may not pay.  The other alternative is to find another plastic surgeon that is willing to remove 500 grams or pay for the procedure yourself.  There have been occasions where I have removed different amounts from each breast, for example: 600 cc's from one side and only 400 cc's from other side, but the average comes out to 500 grams per breast and I have been reimbursed.  This is based on a theory that weight removed cures breast pain.

Best of Luck,

Gary Horndeski, M.D. 

Insurance approval for breast reduction can be frustrating. BCBS has a relatively straightforward checklist of things that they want to see for approval. In general, if you meet all of the requirements, approval for surgery comes quickly. But if there is one element missing, it quickly is denied. That does not mean that an appeal will be futile. It just means that more explanation needs to be offered as to why the procedure is still necessary. I have done several peer to peer reviews for patients and have found the representatives for BCBS to be very understanding. I would suspect that if you have your documentation of back and neck pain and or intertrigo in order, the absoulte volume requirements can be talked through with an appeal. And I can also say that if you are able to proceed with the procedure, you will be extremely glad that you did all that you could to make it happen. (even if it means paying out of pocket.)

Every insurance plan has their own unique criteria on whether they will
cover a breast reduction. More and more, we are seeing plans where a
breast reduction is not a covered benefit. If it is a covered benefit,
some insurance plans set a minimum required amount of tissue to be
remove in order to met their threshold for coverage. Some set the amount
in relation to your BMI (height and weight). Others require extensive
medical records documenting neck pain, back pain, and history of rashes.
The other alternative is to opt for a breast reduction as a self-pay
option. Start by visiting with a board certified plastic surgeon to
learn more about your options.Best wishes,Dr. BasuHouston, TX

Generally breast reduction criteria through insurance companies are defined by a form using weight and height. This results in a numerical number which is compared to a standardized chart.  Appeals can vary from each insurance company. 

It is worth appealing if you have additional supporting information. You don't want to be in a situation where you're surgeon has to take too much off just to meet payment criteria. 500 grams is pretty typical even though 400 grams is likely to alleviate your symptoms.

Insurance companies often refuse coverage the first time. THE BEST WAY to get your case covered is this. If the coverage is through a reasonable sized company, go to the HR dept and have them intercede on your behalf. The insurance company does not want to lose the account with them
This is particularly true if the company shops its medical ev yr or two. That's the harsh reality. Who has more klout? It's as simple as that.

No, appealing the insurance company's denial may not be a waste of time. However, adding additional support to your case ( from primary care physician, OB/GYN, physical therapist…)  maybe helpful. Otherwise, seeking consultation with another plastic surgeon ( who may have a different opinion as to how much tissue can be removed from each breast)  may be helpful.

Best wishes for a successful outcome.

Without an exam it is hard to say what the 400 gm reduction would mean.  If it leaves you flat as a pancake I would not recommend it.  As for coverage, the insurance companies set their own guidelines.  As a surgeon, I want to create a nice looking breast not to worry if I took enough off to appease the insurance company.

If the reason for the denial was based on failure to take out 500 grams, then I would anticipate that you will not prevail on appeal. Insurance companies understand that, once you fall below the 500 g standard, in a patient of your height, honestly, you are looking for a lift for cosmetic purposes and the operation would not be medically necessary. I disagree that 400 g is a significant amount of remove on a patient who is 5'(' tall. What is the "everything else" you can prove? Losing weight would not increase the amount of gram weight to be removed. You should certainly exercise your right to appeal but, understand that, on appeal, the standards are tougher to buck than on the initial approval.