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

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.

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.