My insurance told my my breast reduction surgery would be considered cosmetic and wouldn't be covered at all. I am 20 years old with a bra size of 36J I grow at least two cup sizes a year and have had multiple doctors tell me I need to get this done. I have tingling sensations in my arms, headaches, sleeping is extremely difficult, and horrid back and neck pain. Is there anyway I can get help?
Brittany,
Insurance coverages are like cars. Some are real basic like a Dodge Neon with very little extra’s. Often this is called catastrophic insurance. Some have much better components with broader coverage. Insurance companies determine heath care coverage not doctors. Consider switching to an insurance plan that covers the service you desire. Or, consider paying for it yourself. It is no different from purchasing a ATV or motorcycle. Often ASPS members will offer a package price for a surgical service like a breast reduction.
Best,
Gary R Culbertson, MD, FACS
From your description it should be covered. You need to look at your policy with your doctor, see what documentation the policy requires to meet coverage criteria, do what needs to be done to meet those requirements and then have your surgeon submit that documentation to the insurance company for coverage preauthorization. The only insurance that specifically excludes the procedure that I know of is Medicaid.
Based on your description, Breast Reduction for you, meets all the criteria for a Reconstructive procedure. It would be in the interest of your insurance company to have you undergo this procedure. This would save a lot of expense incurred on treating medical problems arising from untreated macromastia.
Dear Brittany,
Hello and thank you for your excellent question. Dealing with insurance companies can by challenging. My best recommendation is to appeal this decision. It is best to answer your question during a face-to-face evaluation, when you can discuss your goals and expectations for the procedure, and you can have a physical examination to evaluate for that procedure. I recommend that you find a board-certified, or board-eligible plastic surgeon with whom you are comfortable. Be sure to have all of your questions answered during a face-to-face meeting with your surgeon, and review before and after pictures of similar patients whom have had this procedure. If you have any questions, call our office for assistance. Good luck!
It sounds like you are a great candidate for breast reduction. Most patients get immediate relief after the surgery and it changes their lives in so many positive ways! Find out the cost and check into Care Credit as well. Many insurance companies don't cover breast reduction but most hospitals have reduced rates for self Pay surgery. I consider all breast reductions medically necessary but it doesn't mean insurance will pay for it. Don't let the insurance company dictate your health care. Good luck to you!
Unfortunately with your plan not covering the procedure your options remain either to change insurance companies at your next opportunity and re-file for coverage, or you would need to pay for the procedure out of pocket.
Insurance used to cover breast reduction just based on the weight reduced. This has changed markedly over the years and it varies by company as well as by individual policy. In general, the criteria are weight reduced, symptoms, length of symptoms, non-response of the symptoms to other interventions (antibiotics, bras, therapy, etc. which is DOCUMENTED MEDICALLY), and proving that those symptoms are not due to anything else. Do those criteria make sense? Often no. But that is what the companies do. Most are also refusing to look at photos for evaluation.
Even if your company "agrees" that it is covered, that is not a guarantee of payment. It is really difficult to get a predetermination these days which is an assurance of payment. Otherwise you can get stuck with the bill.
What does this all mean? It is difficult to get these paid. You either have a long process or consider doing it as a cash pay case. And work with your elected officials (state & federal) to get this changed.
I am surprised and what we would do would be to resubmit to your carrier with further docum,entation and photos.
Dr. Edward Jonas Domanskis is Certified by the American Board of Plastic Surgery
Newport Beach, San Francisco,Miami, EU, Anguilla,Nassau
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Assistant Clinical Professor of SurgeryWOS-Plastic,University of California (Irvine)
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