Peer to peer interview during insurance investigation. Does anyone have any suggestions for success?

One of the most important things you and your doc can do is understand the exact plan requirements. These vary, and if you do not adhere to them to the letter you will be rejected. When planning an appeal in case of denial, this is even more important.Check the link out on my website "Tips on Getting Insurance Coverage" that explains the process in detail and has links to various plan requirements.You may also Google "Cigna Medical Policy Reduction Mammoplasty" to get straight to their page on their requirements.

I'm sorry to hear you are reaching a roadblock. Your surgeon's office sounds like they are doing everything possible to get you approved. Documentation of your symptoms and exam, photos, and possibly a further review of your  is basically all that can be done. The review may or may not get you approved. When I do a peer to peer, I usually try to schedule it at the end of clinic so that I am reachable by the other physician. But, part of the slow down is the insurance scheduling that time. I hope it is successful for you!

Thanks for your question. As someone who does a lot of reductions, it is very frustrating for the surgeon and the patient to get breast reductions approved. 20 years ago everyone was approved, 10 years ago a lot were approved; but nowadays they are uncommonly approved. The insurance company either fails to think it is not medically necessary or they simply make it an exclusion. When a plastic surgeon does a peer to peer, the "peer" is rarely even a plastic surgeon and simply reads the stock answer for that particular carrier. I have had conversations where the recommended amount of resection was 600gm in a breast that only weighed 500gm. It is ridiculous. My point is that the surgeons try to represent the patient but the insurance company is unlikely to budge. It does not however translate to "it won't be effective". On the contrary, almost 100% of breast reduction patients are satisfied and are very happy they did it. Best of Luck!