I Just Found out That Breast Reductions Are Excluded from my Health Insurance Policy?

Question

Is there any way around that through the appeal process? Or anything else that I can do?

Ronald J. Edelson, MD · Answer

you should find out more of the specifics regarding your policy. They might cover it but often there is a waiting time with a new policy for elective procedures. Unfortunately, however, exclusion of certain procedures from coverage is going to become more and more common as insurance carriers try to improve their bottom line by cutting out procedures it considers to be what they feel is a luxury as opposed to a necessity. but do not give up,on your insurance quite yet. Oftentimes, what is really needed is persistence on your part.

Jeffrey Zwiren, MD · Answer

Unfortunately insurance companies are allowed to exclude some procedures. This is becoming a common practice with procedures such as a breast reduction which has proven health benefits for the patient. The job of the insurance company is to avoid paying for procedures. It is an unfortunate consequence of the health care problem in America. You may file a complaint with the insurance commissioner of your state.

Darryl J. Blinski, MD · Answer

If the exclusion was in your original health insurance contract, that you signed, than NO option! Sorry but this is health care in 2012.

Steven Wallach, MD · Answer

Sorry to hear that, but insurance companies are more and more not approving breast reduction surgery. Welcome to 2012 medical care! Certainly appealing may help, but you can also pay for it yourself if it doesn ot get approved.

Andrew Jimerson, MD · Answer

I am finding more and more instances of breast reduction surgery being excluded from coverage by health insurance plans. Unfortunately, it is unlikely that your appeal will be successful. You could consider exploring a different insurance carrier, but even when covered, there are generally very strict criteria. You may wish to consider saving for the procedure and paying out of pocket. This allows you to pick your plastic surgeon without being limited to a list of doctors proscribed by your insurance plan. It also provides you the freedom to determine whether or not the surgery would benefit you without having to go through the hoops (like courses of physical therapy, anti-inflammatory medication and repeated visits to your general practitioner) required by many insurance plans.

Tom J. Pousti, MD · Answer

There is probably not much you can do if the procedure is “excluded” out right. Of course, other options include a change of health insurance plan if possible or gradual saving for the procedure.

	 Don't give up;  breast reduction surgery is one of the most patient pleasing operations performed.

Barry L. Eppley, MD, DMD · Answer

If breast reduction is a specific policy exclusion, then you have no recourse, other than in the future switching to a new carrier and policy. It is becoming increasingly common than such procedures as breast reduction are being excluded as non-essential medical care.

Peter E. Johnson, MD · Answer

Exclusion for breast reduction may be excluded from insurance outright, or inclusion criteria might be so restricted that few will qualify. The appeal process is stacked against you, and sometimes when open enrollment comes around it is time to switch carriers.

Robert T. Buchanan, MD (retired) · Answer

There is nothing you can do to compel your insurance company to cover a breast reduction if the policy you have excludes it. This is becoming more and more common. It is so common where I am that the majority of breast reductions I do are paid by the patient. This would be an option for you. If you do not have the money readily available, then you can finance the reduction through companies like Care Credit, a service available in most plastic surgeons' offices.

Ronald V. DeMars, MD (Retired) · Answer

The insurance company has to live up to its contract with you but it does not have to go beyond the contract, so if the policy specifically excludes Breast Reductions, as some do, then that is probably the end of it. In the past several years at least half of my breast reduction patients pay for their surgery as a cosmetic procedure because of insurance exclusions.

I Just Found out That Breast Reductions Are Excluded from my Health Insurance Policy?

Answers (10)

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