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

Question

I have started my request for a breast reduction. After a few bumps (office sending docs to wrong place) Cigna is asking for a peer to peer interview. We have barely begun the process. My pics are still in snail mail while docs have been faxed. Isn't this odd at the beginning? My doc's office mentioned this is usually last resort as well as extremely difficult since you can imagine trying to find the time to get two doctors to talk to each other. Does anyone have any suggestions for success?

John LoMonaco, MD, FACS · Answer

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.

Jennifer Lauren Crawford, MD · Answer

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!

M. Scott Haydon, MD · Answer

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!

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

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

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Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.