Under BlueCross BlueSheild Carefirst program, can Breast Reductions not be deemed medically necessary until post op evaluation?

Your surgeon can contact your insurance company and, almost always, find out in advance if the surgery will be covered. It should be a very straightforward process. 

Most insurances will do what is call a Pre-Determination for Medical Necessity.  It is a process and may take a couple months but it can be done.  They won't give you an actual authorization number but they will review your surgeon's notes as well as your primary care and physical therapy notes to determine if surgical intervention is medically necessary.  If it is determined that your case is medically necessary then it is typical that they will cover the surgery.  With that being said some Plastic Surgeon's will collect payment in full up front and when the insurance pays, you will be reimbursed. All the best to you!

Thanks for your question. Dealing with approval from any of the insurance companies is frustrating for all parties. In our area we provide documentation and photos along with expected amount to be removed. A letter of predetermination is then issued either denying or approving the surgery. If you personally contact them after this submission it may get expedited. 300gm is a small amount to approve, but that doesn't mean it won't relieve your symptoms. It just means they don't want to pay for it. Best of Luck!

It sounds like your carrier used to do preauthorizations for breast reduction, but have stopped doing so. Unfortunately, this is their call. My hunch is that the carrier expects fewer women will go through with the procedure were there uncertainty about coverage. I suspect that had they previously decided that the procedure were medically necessary by pre-authorizing the procedure before, they would be hard pressed to say later that it was not.All the best. 

Unfortunately, it can be frustrating when dealing with health insurance companies; they are in the position to be able to “change the rules” when it comes to coverage for breast reduction surgery. You may want to double check the information received with another official from the insurance company. When I see patients in consultation for breast reduction surgery, I remind them that this operation is one of the most patient pleasing operations performed;  it is worth being patient and persistent when dealing with health insurance companies. Best wishes.

rKtx27,     You may need to actually write a letter to the insurance benefits and pre-authorization department yourself, as they will be much more careful about what they say to you in response, as well as providing you with paperwork documentation.  Also, BCBS may be more likely to respond favorably to a customer request, than to a call from a doctor's office.  Basically it is easier for the insurance company to say no if they go through the MD office. Your doctor can provide the usual ICD-9 diagnosis code and CPT procedural code that they use for Breast Reduction, though they are usually 611.1 and 19318-50 respectively.  If they wait until after the procedure is done, it is then easy for them to retrospectively deny the procedure, in some circumstances, even when they had approved the surgery before it was done.  This is one of the frustrations that Plastic Surgeons have with dealing with insurance.  I hope that this helps.     Best wishes,     Tom DeWire, MD, FACSRichmond, VA