Getting a breast reduction covered when I have a contract exclusion. Any suggestions?

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!

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.

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.

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.

Depending
on your particular health insurance plan, breast reduction surgery may be
considered a covered benefit. Some insurance carries may cover your breast
reduction surgery based on the size of your breast, your body habitus, and the
severity of back, neck, and shoulder pain caused by your large breast. Breast
reduction surgery is generally considered a reconstructive procedure and may be
covered by health insurance when it is performed to relieve these medical
symptoms. Many insurers determine whether to categorize breast reduction
surgery as reconstructive surgery based on the amount of tissue that will be
removed. Breast reductions involving removal of small amounts of tissue may not
be covered by your insurance. Similarly, some insurance plans have exclusionary clauses that do not cover breast reduction. Insurance policies vary greatly and even when pre-certification is successful it is not a
guarantee of payment. It sounds like your only option at this point is to pay out of pocket or switch insurance plans.

You can always have a breast reduction done if you pay for it out of pocket. Any experienced board certified plastic surgeon will be able to quote pricing for breast reduction just like they would quote pricing for breast augmentation or tummy tucks.Unfortunately, we see more and more insurance companies write contract exclusions for breast reductions into their policies. There is no recourse that we know of except to go to your human resource department and ask them to negotiate the option back into next years contract. It would of course then raise premiums for all members. We have not found one single Affordable Care policy yet that covers breast reductions.You may want to consider the surgery out of pocket. Most women find the procedure to be life altering. Look at what your current insurance co-pays and deductible are and compare the pricing of an out of pocket procedure. You may be surprised.

By "submitting a claim" you imply that the surgery has already been done.  If you have an exclusion and the surgery has been done, then you are pretty much out of luck. It is like having car insurance that states that you won't be covered if you hit a mail box. You hit a mail box and ......sorry.   If you are asking about getting pre-approval from a company with an exclusion on your policy then you may have more options.  You could switch companies or policies that don't carry the exclusion.  You could also ask for a peer to peer review between your doctor and the medical director for the policy to see if there is any wiggle room in the exclusion.