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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?

LessBreastIsMoreFit's provider

Dr. Wayne Ledinh, MD

I had a consultation with Dr. Ledinh. He was very courteous, straight forward and prompt. I had no issue with understanding what he feels can be accomplished with a breast reduction. My appointment went as follows: I arrived to my appointment about 10 minutes early. The office is clean and very new looking. There were three receptionist working, one addressed me as soon as I approached the counter. She was cheerful and polite. Checked me in and handed me paperwork to fill out. I sat down with the standard type of medical history and symptoms paperwork. At my exact appointment time, I was called back by a nurse. My husband was with me and we were both greeted cheerfully. I was invited in an examination room, asked a few questions about history of complaint and then had my weight taken. The nurse then placed a monitor in front of us that played a video demonstrating reasons, procedures and results of breast reduction. The examination room was very clean, up to date and well lit. Following the video, approximately 15 minutes after being assigned the room, Dr. Ledinh and his nurse returned. He introduced himself to my husband and I. We discussed my history of weight gain, discomfort, office visits and symptoms. He then asked permission to do photographs and measurements. We discussed what size I could be should he remove the amount required by my insurance and handed me a breast implant that roughly showed the amount that would be removed. He was clear to state that everyones results are different. He was very clearly spoken, polite and never once was I uncomfortable with the exam. He also spoke with my husband in regards to his feelings, post-op care and his desire to keep me overnight at the local surgery center post-op. Overall, I feel the practice is clean, well organized and very well staffed. Dr. Ledinh explained everything very clearly and detailed important things to consider. He was never hurried in his exam or discussion and asked several times if we had questions about any part he had explained. He spent approximately 30 minutes with us for the consultation. I am now awaiting approval/denial from my insurance company and will update when I hear something further.

Replies (3)

You would need your dr to determine that the procedure is medically necessary, list your symptoms, and ask for pre approval, but they are saying pre approval doesn't mean they will cover it, they will make a final decision after surgery is over and they have the surgery report with the number of grams removed per side, and that those grams match the chart for your weight. (That's pretty standard). If you pick a provider in your network, and meet their criteria they pay everything, if you pick a surgeon out of network they only pay 60% of the bills.
Thank you so much. I kept trying to figure if it meant it would be covered after the surgery which means they could simply deny it and leave me with a huge bill.
Hi! Did you get approved on the new insurance? I was reading your posts and one time you mentioned asking where you could get a bra in your size? I would highly recommend bravissimo in the UK (available online and ships to USA) or If you're in the USA, Figleaves or Brastop. You can easily filter by size and they have Several styles and brand abailable
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 (5)

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.
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.
They denied my ps the right for a peer to peer.
Are you kidding me!! What a bunch of crap! Why???
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.
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