I was declined by my insurance for my breast reduction? What to do?

Question

My surgeon told me he was going to take off 800 g, but his nurse stated he filed his papers that he will be taking off 797 g. Bcbs will only cover the surgery if he remove 979 g. I lost the weight to get the surgery now I can't get the surgery. I have sprung my back, I have cuts on my shoulders from my bras, now I have rashes under my breasts that bleed and smell at times. On top of that, the surgeon tells me to appeal it but he don't help with appeals...this is stupid. I don't know what to do

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Typical the surgeon's office will formally perform the appeal on your behalf.   This only makes sense because he doctor will often have a peer-to-peer (doctor to doctor) discussion about your case.  If your current surgeon doesn't or will not provide this for you then you need to find a different surgeon.

J. Jason Wendel, MD, FACS · Answer

Thank you for your question about breast reduction.You may have the surgery performed on a cosmetic basis, or you can always get a second opinion from another qualified surgeon.To be sure, see two or more board-certified plastic surgeons in your area for a full and complete evaluation to make sure you are a good candidate and that it is safe for you to have breast reduction or related procedure.I hope this helps.

Emmanuel Mallol Cotes, MD · Answer

Thanks for sharing your concerns with us. Insurance usually doesnt cover plastics surgery. There is an option to make the procedure you want at an affordable cost, so you will not have to incur financial loans.In this regard, you have the possibility of getting a plastic surgery with high quality standards: with Board Certified Plastic Surgeons, in medical centers that follow international standards of patient safety and in comfortable and supervise recovery places after procedure, all for an affordable investment and reasonably lower than the standard values.In that sense I recommend considering coming to the Dominican Republic, its proximity to the US (45min).the "all year summer" and its political and economic stability, as a remarkable development, have made an excellent and safe destination for medical tourism and specially in Plastic Surgery, which it is already a global reference.Finally, i invite you to contact a Board Certified Aesthetic and Reconstructive Plastic Surgeon of the DR, send your photos and get the free consultation and budget: you'll see, you'll be surprised.Respectfully,Dr. Emmanuel Mallol Cotes.-

C. Bob Basu, MD, MPH, FACS · Answer

Every insurance plan has their own unique criteria on whether they will 
cover a breast reduction. More and more, we are seeing plans where a 
breast reduction is not a covered benefit. If it is a covered benefit, 
some insurance plans set a minimum required amount of tissue to be 
remove in order to met their threshold for coverage. Some set the amount
 in relation to your BMI (height and weight). Others require extensive 
medical records documenting neck pain, back pain, and history of rashes.
 The other alternative is to opt for a breast reduction as a self-pay 
option. Start by visiting with a board certified plastic surgeon to 
learn more about your options.Best wishes,Dr. BasuHouston, TX

Tom J. Pousti, MD · Answer

I am sorry to hear about the difficult time you have had obtaining authorization. As you have found, it can be very frustrating dealing with insurance companies. I would suggest you write an appeal letter and have your physicians do the same. Look for the insurance companies' "criteria" and find as much support to meet these criteria. Be persistent.Best wishes.

Jeffrey Zwiren, MD · Answer

Weight requirements mandated by the insurance companies to approve a breast reduction are ridiculous.  As a plastic surgeon I work for my patient and not the insurance company.  I do not think the insurance company will take any responsibility if you have complications after surgery if your plastic surgeon removes the mandated amount of tissue.  The plastic surgeon must use his judgement to perform a safe procedure.  A peer to peer review may be needed to get you approved.  Many times this is what is required to complete the process.

Steven Wallach, MD · Answer

Sorry, but welcome to medicine in 2015. It can be very difficult to get approval for what was once a common issue to get approval in the past. You can always self-pay.

Robert L. Kraft, MD, FACS · Answer

It sounds like BCBS is using the Schnur scale to calculate the gram weight that must be removed to qualify in conjunction with your height and weight. This cannot be faked because, if the gram weight specified is not removed, the surgeon and hospital will not be paid. Recently, some insurers have upped the ante from 750 grams to 1000. Generally, if the surgeon believes the case is defensible, he will file the appeal on your behalf.  The alternatives are accepting the BCBS minimum even if that is smaller than you would like to be but which will alleviate the symptoms or to have the procedure on a fee for service basis.

Sugene Kim, MD, FACS · Answer

Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Please check your insurance policy to see whether breast reduction is a covered procedure. Often times, insurance company will dictate how much breast tissue to be removed. Please visit an experiences, board-certified plastic surgeon to learn about the procedure, its cons and pros, benefits, and alternatives. Please contact your insurance carrier to learn about inclusion and exclusion criteria. Best wishes.

Mark Gaon, MD - Account Suspended · Answer

Schedule an appointment to talk to your surgeon about an appeal. Often all it takes is for the surgeon to call your insurance company to request a peer-to-peer conference call to discuss your case with another doctor who works for the insurance company. If your doctor is not willing to do this for you, then consult with another surgeon.

I was declined by my insurance for my breast reduction? What to do?

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