Insurance Appeal- How Do I Ensure My Reduction Is Covered?

My insurance denied my breast reduction because my surgeon did not submit a specific number of grams to be removed. After examining me, she said she could remove the amt they suggested. They submitted an appeal, but my surgery date is fast approaching. I called my insurance co. and they tell me that all the criteria was previously met except the amt of tissue and because of that it is still in appeal. Is it safe to assume that the procedure will be covered if she removes the recommended amt?

Doctor Answers 11

Dealing with insurance

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Every insurance plan has there 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. Basu

Houston, TX

Breast Reduction - Insurance Coverage

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No, it is not safe to assume that.  What is safe is to assume nothing.

You should work quickly to coordinate the submissions of your plastic surgeon's office and your insurance company, and indicate to all involved that you will not proceed with the surgery on the currently scheduled date until everything has been okayed IN WRITING.  Doing otherwise risks having your surgery not be "covered," and exposes you to significant charges after-the-fact.  There is no need for this, so it's well worth it for you to pursue this as needed BEFORE having any surgery.

I hope that this helps, and good luck,

Dr. E

Breast Reduction-Insurance Appeal

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I would recommend that you not have your surgery unless you get the approval, once the surgery is done it is much harder and you may end up having to pay out of pocket. If you have your insurance through employment, see if your HR department can help you expedite the process so you can keep your surgery date. Also, you should call them everyday, get the name of a contact person you can speak to each time who may help you! Good luck.

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 80 reviews

You can never guarantee an insurance company will pay for your surgery

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I know of breast reduction cases where surgery was precertified by the insurance carrier, the patient achieved resolution of all symptoms, both the surgeon and patient were very pleased with the surgical result and the carrier paid for the surgery. Several months later, the carrier sent a letter of adverse decision and a demand for repayment because the minimum amount of tissue was not removed. I know of no way to accurately predict how much tissue will be removed during surgery. The removal of specific minimum amounts of tissue to ensure that the surgery is being done for non-cosmetic means is based upon an antiquated 1991 article of which the insurance companies use to make their decisions in many cases.

Current plastic surgery literature supports the theory that the amount of tissue removed does not correlate with relief of symptoms and that women with symptomatically large breasts can usually anticipate significant relief even when the amount of tissue removed is less that determined by older criteria. Until the insurance carriers are on board with this, obtaining insurance converage for breast reduction surgery will continue to remain a battle in some cases. I recently successfully appealed a denial for precertification in the case of a 62 year old woman whose breasts laid across her mid thighs when sitting upright, not withstanding her horrific symptoms. The carrier maintained the denial was because the surgery was "cosmetic in nature".

Mark D. Epstein, MD
Stony Brook Plastic Surgeon
4.9 out of 5 stars 243 reviews

Insurance Coverage for Breast Reduction

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It would seem that if they told you that it should be covered if the required amount of tissue is removed you could go ahead. I would not believe anything unless it is in writing from an insurance company. If it is in an appeal, your best bet is to call and try to get an expedited review of your appeal since your surgical date is fast approaching. If you do not get a written authorization prior to your surgery, I would be hesitent to proceed until you do. Your doctor can try to contact your insurance company but they will listen more often to the patient who keeps calling since you are their "customer" not the doctor.

Scott R. Brundage, MD
Grand Rapids Plastic Surgeon
4.8 out of 5 stars 26 reviews

Breast reduction

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Insurance criteria for breast reduction is so variable and insurance companies are so capricious.  Find out what there criteria are and if yoru surgeon gave an approximate # of gms for removal, then your should call yoru isnurance company yourself to push throught the approval. 

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Breast Reduction

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I agree with Dr Gutowski below, not just because he is Polish, but because he has a good point.  Insurance may cover breast reduction for some women. It depends on the patient’s breast size, body type, and symptoms. Most insurance companies have a formula based on your height, your weight, and how much your surgeon estimates will be removed. Usually removal of about a pound from each breast is required for insurance coverage. Health care providers are mercenary about denying coverage for breast reduction. They don’t care if your clothes don’t fit or you can’t exercise. In my experience, they don’t even care about your pain and discomfort, much less psychological embarrassment. It all boils down to your height and weight versus how much breast tissue will be removed. You can’t necessarily pick your desired breast size or shape. To remove less than the insurance company’s formula requires places the procedure in the realm of cosmetic surgery. That means you pay the bill. Your surgeon should get a detailed medical history because some health- care providers demand a history of treatment for back pain to authorize coverage. I measure the breasts and often take photographs to be mailed with the insurance letter. If I don’t comply with the rules, the insurance provider— who holds all the cards—may not authorize paying for the procedure.  All the best!  Dr. Joe

Insurance Coverage for Breast Reduction

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In almost all insurance cases, a Prior Authorization does NOT guarantee that payment will be made. There is not way to know until after the surgery is done.

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
4.9 out of 5 stars 74 reviews

Breast reduction precertification

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I would assume nothing. I will say, performing breast reductions on a weekly basis, I do not understand why your surgeon did not understand that a precert letter which does not contain gram weight would be automatically denied. Your physician's office should be handling this for you. If they do not, then there are many other plastic surgeons out there. It is always better to do it right the first time than to go through an appeals proceeding. The insurance company can delay approval for an additional 45 days because the case wasn't properly presented to begin with. Best of luck! DR K

Never assume breast reduction insurance coverage

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We have found the the only assurance that breast reduction will be covered by your insurance plan is a full perdetermination, and confirmation of coverage in writing. Even with a written coverage agreement it is wise to keep all documents handy, and records of any one you spoke to at the company. The insurance company line has always been that a coverered benfit is not a guarantee of payment for services.

Best of luck,

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 43 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.