Insurance Denied my Breast Reduction Surgery, How Do I Make a Case for an Appeal?

Question

25yrs old, 5'3" and 165lbs and my cup size is 34G, denied coverage for breast reduction based on the Schnur scale. Surgeon wants to remove 250g from left breast and 300g from right but scale says to make a symptomatic difference I'd need twice that removed! The ins. company also deemed it cosmetic due to ptosis (sagging breasts) and the fact that a lift would be included in the procedure. Doubled sports bras cause discomfort and trouble breathing so I can't exercise and lose weight due to pain.

William T. Stoeckel, MD · Answer

I tell my patients that the insurance companies are businesses. They are not going to cover a surgery that seems at all to be simply a cosmetic procedure. I also tell my patients to be honest with themselves. They should not expect the insurance company to cover a procedure that is not medically necessary. If the breast reduction surgery for you is needed to relieve back and neck pain or reduce skin rashes along the IMF, you should not have trouble documenting this being a problem for you. Have your family physician, OBGYN, chiropractor, orthopedist, etc. draft a letter designating what your symptoms are and what measures you have done that have been unsuccessful in relieving those symptoms. Have your plastic surgeon take photos and also draft a letter of medical necessity. Most likely, 250 grams is not enough to qualify for a medically based procedure. You need to be more certain that this is all that needs to be removed in order to relieve your symptoms. If you truly have a medically based case and you have been denied, your surgeon can set up a peer to peer review with the insurance company on your behalf. This can be very effective, but only if there is enough evidence to suggest that you really have a medical reason to complete the surgery.

Adam Tattelbaum, MD · Answer

Thank you for your question,

	As you've already seen is very difficult in this day and age to get breast reduction covered through Medical Insurance.  If you're going to appeal your best bet would be to gather supporting information from Physicians in charge of your care who document that breast reduction will indeed be in your medical best interest.

	Even in this situation some insurance companies simply do not cover breast reduction as part of their plan. This is likely to be covered in your delineation of benefits.

	If ultimately you cannot get Health Insurance to cover this for you many surgeons offer a cosmetic option for breast reduction and even help to set up financing.

	 

	Good luck.

Tom J. Pousti, MD · Answer

Thank you for your question.

	I am sorry that your insurance company denied authorization.  Each insurance company is different with what they want for approval and their criteria for authorization.

	You can try to have your surgeon send an appeal but also include documentation from other doctors you have seen for issues related to the large breasts (ie) chiropractors for back/ shoulder pain, primary care doctor if you have rashes, etc..

	Those supporting letters may help.

	Good luck.

C. Bob Basu, MD, MPH, FACS · Answer

Sorry to hear about your denial.  It is getting more difficult to get reductions covered by insurance.  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

Steven Wallach, MD · Answer

Breast reductions are not all covered by health insurance.  They have made it harder and harder to get covered.  Sounds like you will have to pay out of pocket to get it done.  Good luck.

Insurance Denied my Breast Reduction Surgery, How Do I Make a Case for an Appeal?

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Insurance Denied my Breast Reduction Surgery, How Do I Make a Case for an Appeal?

Answers (7)

Answer: Insurance denial

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