Insurance Denied Coverage of Breast Reduction - How Can I Appeal?

My insurance has denied authorization for breast reduction surgery. What would be the best info to appeal their decision? I have a worn T5 in my curved spine and suffer from low back referred pain as well. I am very tired of living with these conditions. I also have fibromyalgia that my insurance reviewers considered to be the primary cause of my pain. I need some relief!

Doctor Answers 6

Breast reduction and insurance

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Every insurance company is a bit different with regards to coverage for a breast reduction. You should contact your insurance company to find out their criteria.  You would have to appeal the denial as well.

New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Breast reduction and insurance denial: send a 10 pound bra to Insurance CEO

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There are no secret weapons but persistence is a virtue when it comes to insurance companies. Consider taking a 10 pound weighted bra into the CEO of the insurance company and asking him/her to wear it 24x7 for just one week.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Breast Reduction and Insurance Company Appeal?

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Thank you for the question.
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. Be persistent.
Best wishes.

Breast reduction and insurance and costs

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Yes, I would suggest you appeal. We are able to pre-authorize our patients based on the amount that I plan on removing as well as dermatologic problems under the breasts.

Edward J. Domanskis, MD
Newport Beach Plastic Surgeon
4.5 out of 5 stars 28 reviews

Breast reduction insurance coverage

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Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2) Very big reductions (like from an F cup to a C cup) will usually be covered.

3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9) Don't give up. If the first request is denied, demand an appeal.

10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Insurance Breast Reduction Coverage

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What you need to do is talk to your insurance company and see what it takes to get authorized from their perspective.  With that infomation, you can then talk with your surgeon and see what may need to be done.  Some want you to go to physical therapy first, while others want notes from an orthopaedic surgeon, etc.  It can be a struggle, but just keep fighting with them and see what it is going to take.

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.