Why was I denied a breast reduction by Horizon BCBS and what can I do to get them to cover it?

Insurance companies use all different criteria to approve breast reductions and no two insurance companies use the same criteria. In general, they look for prior documentation of back pain from large breasts and prior conservative therapy. Once those have been met, they will use your height and weight to determine how much tissue they want removed for coverage. If you were denied it does not hurt to appeal and see why you were denied. It may take a few months of physical therapy or some other conservative treatment. If they require more breast tissue removed than your surgeon feels comfortable taking, you may have to discuss having a breast reduction performed cosmetically (outside insurance.)

From your description it seems as if you are a good candidate for breast reduction. Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Thank you for your question.Unfortunatly this happens often.You can appeal this decision and see if they reverse it. I suggest you call your insurance company and see if this is a covered surgery for you.Good luck!

Whether or not sure insurance company will cover breast reduction is uncertain even with the previous denial. Many insurance companies deny any claim the first time it comes through the door. Certainly an appeal would be worth it but don't count on the insurance company to reverse its initial decision.

I have been told by industry insiders that some insurance companies' first rule of defense is to deny the first request for pre-authorization, hoping that you will be discouraged and simply blow away. Read your policy and determine if breast reduction is a covered procedure for treating macromastia. If covered, you should qualify, but insurance companies prefer to keep their own enigmatic criteria for approval confidential, so it's anyone's guess as to why they may deny you coverage. Appeal, call them, write letters, and be a nuisance. But in the end, as much as I hate to say it, a brief letter from an attorney may unlock the gate.

Welcome to the world of medicine in 2015. Insurance companies are more and more denying what in the past were cases that would get approved.

It is always a good idea to appeal but before doing do you should review the carrier criteria as well as the documentation submitted by your surgeon. Was it your weight, breast size or did you fail to fulfill criteria for conservative medical management? Most carriers now require documented chiropractic or physical therapy for at least three months, occasionally six. If your insurer expects this, then seeking preauthorization without it us a guarantee for denial. Some insurers waived this for gigantomastoa, but I am seeing this less and less. They want you to jump through hoops, even though they wind up paying for the PT because they are well aware that many patients will not follow through!

In my experience, insurance companies deny breast reductions for one of two reasons. 1. The procedure is not a covered benefit, meaning it was not checked off when signing up for your policy. If this is the case, at the next open enrollment, make sure that this procedure is covered by the new policy. 2. inadequate documentation. Be sure to see your family practitioner and note the discomfort and pain that your breasts are causing. I know its foolish, but you have to have a paper trail and the recommendations of your family doctor are essential.  They may recommend physical therapy or chiropractic for symptoms (neither of which will make your breasts smaller, obviously). With that paper trail that you have tried everything short of surgery and have not had relief, your chances are much better to have insurance cover the procedure. If all that fails, speak to a Board Certified Plastic Surgeon about doing the procedure off insurance. A number of payment plans are available to make the procedure affordable. You won't regret it. My breast reduction patients are the most happy in my practice!  Best Wishes!