Usually. When we meet with a patient we discuss their symptoms and history of treatment, exam and measure the breasts, record their height and weight, and take photographs. After the visit, we will write a letter to your insurance company discussing our findings and ask for a predetermination as to whether the procedure will be a covered under your policy. Depending on the company, we usually get a response in 1-3 weeks. Once they have given their approval, we can arrange to get your surgery scheduled. While breast reduction surgery is a covered benefit under most policies, some plans do not provide it as a benefit. Unfortunately, if your plan excludes coverage of this procedure, there is simply no way we can get around this. In order to have the operation, you would have to pay for it yourself (many patients do and consider it money well spent) or wait until you change to a different insurance plan that covers the procedure. Sometimes the amount of tissue we plan to remove does not meet the threshold for coverage by your insurance company. For example, we might estimate that we will be removing 500 grams of tissue (a little over a pound) from each breast at the time of surgery but your insurance company guidelines say 800 grams need to be removed from each side for the surgery to be covered. In this case, we are in a bind. If we remove enough tissue to get the procedure covered, the result might be very disfiguring for the patient. We do our best to avoid this situation by accurately stating the amount of tissue we will remove in our predetermination letters. In all honesty, there are a few insurance companies that set their threshold for coverage so high that only patients with ENORMOUS breasts could ever qualify. Fortunately, most insurance companies are more reasonable. If you are denied coverage, the letter from the insurance company will usually give an indication why they have reached this decision. If it is an “excluded benefit”, then you’re out of luck. No amount of appeal will change this unless your policy coverage changes. Sometimes they may request additional information such as records from your primary doctor, chiropractor, physical therapist, etc., documenting your efforts to seek non-surgical relief from your symptoms. Some companies have requested we call their physician reviewer directly for a phone conference to discuss the patient and we have sometimes (not always) been successful. While it is not really our job to coerce your insurance company into paying for your surgery, we will do our best to accurately convey our findings and opinions and help make the case for coverage when we feel you have a valid claim and help guide you through the process.
