POSTED UNDER Breast Reduction Reviews
38 Years Old, 5'6", 187.8lbs, 36J
UPDATED FROM LessBreastIsMoreFit
2 months post
Nearing 40 Now. New Insurance
$5,000
Hello again all. This is what I received from my new insurance company when I contacted them in regards to breast reduction:Benefits for reduction mammoplasty procedure are provided when all of the following criteria are met:
1. The procedure is necessary to correct documented physical symptoms and/or documented functional impairment.
2. The attending physician in the hospital record documents a detailed description of the physical symptoms and/or functional impairment expected to be relieved by surgery.
3. And the following is documented.
Patient Weighs Breast Tissue Removed
0-130 lbs. = 400 or more grams each breast
130-200 lbs. = 500 or more grams each breast
200 + lbs. = 600 or more grams each breast
Pre-determinations are no longer performed by CareFirst. This indicates current criteria used by our medical review department to determine medical necessity. This is not a prior approval of benefits and all claims are subject to medical review.
Your benefits are considered at 100% of the allowable amount for In Network providers and considered at 60% of the allowable amount for out of network as well as subject to your annual $600 deductible. Please be advised non-participating provider can balance bill for any amounts not covered by your plan.
Can anyone explain to me if this means I get it done and then they determine if it was warranted?
1. The procedure is necessary to correct documented physical symptoms and/or documented functional impairment.
2. The attending physician in the hospital record documents a detailed description of the physical symptoms and/or functional impairment expected to be relieved by surgery.
3. And the following is documented.
Patient Weighs Breast Tissue Removed
0-130 lbs. = 400 or more grams each breast
130-200 lbs. = 500 or more grams each breast
200 + lbs. = 600 or more grams each breast
Pre-determinations are no longer performed by CareFirst. This indicates current criteria used by our medical review department to determine medical necessity. This is not a prior approval of benefits and all claims are subject to medical review.
Your benefits are considered at 100% of the allowable amount for In Network providers and considered at 60% of the allowable amount for out of network as well as subject to your annual $600 deductible. Please be advised non-participating provider can balance bill for any amounts not covered by your plan.
Can anyone explain to me if this means I get it done and then they determine if it was warranted?
UPDATED FROM LessBreastIsMoreFit
2 months post
Beginning the whole process with a new insurance.
Hello. I am giving it a go...again. We now have BCBS Advantage (it covers chiro care!!!) and will be getting more opinions on if a breast reduction can be accomplished under coverage.
Replies (0)
UPDATED FROM LessBreastIsMoreFit
18 days pre
Appeal Denied
UHC decided to deny my appeal. They sited that it is a policy exclusion....again. Again they give no code for the denial and no further information. I again contacted customer service and inquired about the recorded phone call being pulled from early August during which I was told breast reductions are covered. Nobody knows what I am speaking of. I have been encouraged to file another appeal, with the same company.
Replies (1)
C
October 14, 2016
I am so sorry you're going through this!!!!!! I had a difficult time with UHC care as well. My family doctor that referred me to the plastic surgeon is the one who called in and got me approved due to my back issues. What does "policy exclusion" mean?? They denied me at first saying not enough tissue could be removed. They wanted 500g off each side and the surgeon could only take out 500g on my left but no more than 300g on my right. So UHC denied me for lack of medical necessity but a physician could call in the peer to peer and give another medical necessity.
L
October 15, 2016
They are claiming that it is a policy exclusion because my insurance does not cover cosmetic surgery. I am looking at having 670g removed from each side, inpatient, and some lipo under arms. That is what the paperwork my ps sent in states. They say this is cosmetic surgery not medical surgery.
L
C
L
October 15, 2016
They contacted my phone twice and my PS's office 5 times to schedule the peer to peer. When he contacted them to schedule, Pam (the p2p receptionist) told him it was not protocol for them to allow this when it is a policy exclusion~it will not happen~have a good day.
Replies (2)