I submitted a claim for a breast reduction and my claim was denied after not being deemed medically necessary. After completing 6 weeks of physical therapy and seeing a chiropractor I was not denied by told the surgery was a contract exclusion on my policy. I have blue cross blue shield of texas. Is there any way around a contract exclusion even if the surgery as been deemed medically necessary. I am 22 years old, 5'2 and weigh 125 with a 34DDD chest.
Answer: Insurance and Breast Reduction You can try to appeal the decision, but if that fails, your only choice will be to pay out of pocket or see if you can switch to a policy that covers breast reduction during the open enrollment period. Good luck!
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Answer: Insurance and Breast Reduction You can try to appeal the decision, but if that fails, your only choice will be to pay out of pocket or see if you can switch to a policy that covers breast reduction during the open enrollment period. Good luck!
Helpful
November 11, 2015
Answer: Breast reduction approval with a contract exclusion Each insurance company is different, but I just had a patient with a contract exclusion get approved after she appealed the denial. When a company decides prior to surgery regarding coverage, that's called predetermination. When they make that decision, they typically send a letter to the doctor and the patient. On that letter are instructions that you can follow to appeal the denial. I suggest you include as much documentation as you can that the medical issues you're having are significant and have failed to improve despite your efforts (medical records from your doctor, physical therapist, chiropractor, etc.). This appeal is likely to be reviewed by an actual doctor (though one that works for the insurance company) and could be successful. If it's not, I don't know of other options for you other than paying for your surgery as an out-of-pocket expense.
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November 11, 2015
Answer: Breast reduction approval with a contract exclusion Each insurance company is different, but I just had a patient with a contract exclusion get approved after she appealed the denial. When a company decides prior to surgery regarding coverage, that's called predetermination. When they make that decision, they typically send a letter to the doctor and the patient. On that letter are instructions that you can follow to appeal the denial. I suggest you include as much documentation as you can that the medical issues you're having are significant and have failed to improve despite your efforts (medical records from your doctor, physical therapist, chiropractor, etc.). This appeal is likely to be reviewed by an actual doctor (though one that works for the insurance company) and could be successful. If it's not, I don't know of other options for you other than paying for your surgery as an out-of-pocket expense.
Helpful
Answer: Breast reduction and insurance coverage If you have already gotten a letter denying coverage due to a policy exclusion, then it is very difficult to overturn that. You have the chance to switch your insurance plan during open enrollment or pay for the procedure yourself. There are financing options available that may make it affordable. Discuss your options with your surgeon and come up with a plan that is best for you.
Helpful
Answer: Breast reduction and insurance coverage If you have already gotten a letter denying coverage due to a policy exclusion, then it is very difficult to overturn that. You have the chance to switch your insurance plan during open enrollment or pay for the procedure yourself. There are financing options available that may make it affordable. Discuss your options with your surgeon and come up with a plan that is best for you.
Helpful
November 11, 2015
Answer: Getting a breast reduction covered. Breast reduction in the Chicago area can be quite difficult with some plans and insurance appeal can help, however under affordable care there are policies with an exclusion for breast reduction. This means your policy does not cover the procedure, ever. With open enrollment you can consider a switch, and we find the HMO plans easily worked through, and if you cannot change, reduction can be made affordable as an office procedure.
Helpful
November 11, 2015
Answer: Getting a breast reduction covered. Breast reduction in the Chicago area can be quite difficult with some plans and insurance appeal can help, however under affordable care there are policies with an exclusion for breast reduction. This means your policy does not cover the procedure, ever. With open enrollment you can consider a switch, and we find the HMO plans easily worked through, and if you cannot change, reduction can be made affordable as an office procedure.
Helpful
November 11, 2015
Answer: Getting a breast reduction covered when I have a contract exclusion. Any suggestions? Depending
Helpful
November 11, 2015
Answer: Getting a breast reduction covered when I have a contract exclusion. Any suggestions? Depending
Helpful
