What Do I Do After my Appeal for my Breast Reduction is Denied?

Question

I sent in my appeal for a denial of my breast reduction surgery and I was denied again. My only option at this point is a 2nd level hearing. According to my IC, the surgery is not covered in my plan/benefits. I'm ready to give up at this point and I'm very upset/discouraged. Any suggestions?

Miguel Delgado, MD · Answer

Some insurance plans specifically state that breast reduction surgery is not a covered procedure. It sounds as if this is the case for you, and if so an appeal won't help. What you might consider doing is when your insurance has open enrollment (usually in November) you might try to switch to a plan that covers breast reduction. It may be more expensive but after one year you can switch back. See if someone in your HR department can help you. Good luck!

Steven Wallach, MD · Answer

Welcome to medicine in 2013! But it is very difficult to get insurance approval for breast reduction because they often think that it is cosmetic. If you do not get approval, then your only choice is to pay for it yourself.

Anureet K. Bajaj, MD, FACS · Answer

I would discuss with your insurance provider as to why your breast reduction is being denied -- are you not meeting certain criteria or is it not a covered benefit at all.  Insurance companies are increasingly making it more difficult to obtain coverage for breast reductions.  

	 

	If this procedure isn't covered by your provider, you have the option of paying for a breast reduction out-of-pocket.  Most plastic surgeons do have cosmetic or cash pricing for breast reductions which includes surgeon's fees, operating room expenses, and anesthesia.  You may actually find that this pricing is reasonable and within your reach after saving for a few months.  I would recommend that you discuss all of your options with a board certified plastic surgeon.  Good luck!

Marialyn Sardo, MD · Answer

Talk to your plastic surgeon to help you discern what the issue is. Do they just not cover this procedure or are you not meeting their criteria? Get guidance from your surgeon as to whether coverage is potentially possible in your circumstances or whether you will have to pay for the procedure yourself. There are finance companies and Care Credit that can be helpful

Richard P. Rand, MD, FACS (retired) · Answer

Insurance is trying to make to harder than ever to cover a breast reduction. If all avenues have been exhausted, you can save up and pay the surgeon directly for one. This is very commonly done these days.

What Do I Do After my Appeal for my Breast Reduction is Denied?

Answers (5)

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