I received a denial letter from BCBS AL. Their reasoning was my records didn't show enough breast tissue will be removed (Photo)

Question

I am 5'6” and weigh 120 pounds. I wear extra small/small clothes even with 28H sized breasts. My PS submitted pictures and medical documentation from my primary care doctor showing I get steroid shots for back pain. What else can I do? My PS says my breasts aren't dense enough to remove 500 from each breast. Honestly, I really don't even know what that means. Please, any help will be greatly appreciated. I'm devastated over this.

Vincent N. Zubowicz, MD · Answer

There are no set criteria for insurance coverage in breast reduction. I would recommend that you resubmit a claim as initial denials are fairly common.

Ralph Trey Aquadro, MD · Answer

Sorry to hear that your surgery got denied.  BCBS of AL requires a total of 1000 grams to be removed (or 500 grams from each side).  As was mentioned by a previous doctor, the Schnur scale is an option and was developed to stratify the resection amounts based on body surface area.  BCBS of AL does honor the scale for breast reductions, but only for women 5'3" or shorter.  It may be worth an appeal to see if you would qualify based on your BSA even though you are taller than 5'3".If you get denied again, you may consider getting the procedure done as a cosmetic surgery.  Best,Trey Aquadro, M.D.Auburn, AL

John Michael Thomassen, MD · Answer

Maybe you can search out a second opinion regarding the amount of breast tissue that can be removed.  If the note from your plastic surgeon denotes only a small amount of breast tissue is to be removed, the insurance company will not agree to pay for the surgery.  They want to avoid paying for patients that really only want a breast lift with minimal breast tissue removed.   Based on your photos I believe you should be covered for this procedure.

Jack Peterson, MD · Answer

You should appeal the decision. Based on your given height and weight the Schnur scale ( the math formula insurance companies use to determine medical coverage) shows that you should be approved as long as your PS can remove 310grams of breast tissue or more. Your plastic surgeon should have written that they would remove 310grams or more.You also obviously have medical documentation. Some companies have requirements that you document medical issues for a certain period of time( for example, 6 months, 1 year..etc.) Pretty much every insurance company uses this scale. If BCBS Alabama does not, you should be able to appeal stating that you meet criteria based on the scale. You may want to get a second opinion on your breast reduction. A surgeon ( and their patient coordinator staff) that has experience with dealing with insurance companies, should know the ins and outs of getting patients approved.

Darryl J. Blinski, MD · Answer

Unfortunately today's the health insurance companies will deny most any BR letters. You can ask for a review, submit a second opinion from another boarded PS to re open your file, ask the 1st PS to call the medical director for BC/BS AL to discuss your case. Or just pay for the surgery. Understand if you become a pain in the neck to BC/BS AL you will either be cancelled or made an example. Very rarely does being aggressive actionwork but that is your only option. Plus most plans have a deductible and co pays you need to meet. If that $ amount is over $4,000 than you might find a boarded PS with office surgery suite to do your reduction in the $5,000 ranges...

Bahair Ghazi, MD · Answer

Sorry to hear your having difficulty. From your pictures I think you will have an amazing result following a lift. It is hard to say but  it seems that your plastic surgeon is following all criteria and the decision is out of their hands. I encourage you to consider and appeal then perhaps get a cosmetic quote, if your tissue are in good shape you will be so so happy with your final result. I am always excited when my patients are thin and in good shape with breasts like yours...the result is beautiful. Good luck.

I received a denial letter from BCBS AL. Their reasoning was my records didn't show enough breast tissue will be removed (Photo)

Answers (6)

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