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Nearing 40 Now. New Insurance
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?
Beginning the whole process with a new insurance.
Appeal Denied
Provider Review
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.