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I am a 24 year old female looking for help with my appeal for a breast reduction. I...

Q:

I am a 24 year old female looking for help with my appeal for a breast reduction. I am a 32-DDD and weight about 130 pounds, healthy BMI. I met with a plastic surgeon who explained the process and qualifications to me. My plastic surgeon submitted my claim and it was denied because the amount of tissue removed from my left breast was 150cc less than what my insurance requires; however, my right breast was almost double the required amount for removal. I am currently in physical therapy to help document my neck and back pain. Another reason they denied my claim was that I don't have deep grooves in my shoulders. I need some help - please advise if you think I meet the criteria and have a legitimate claim for appeal.

A:

The number of grams required by the insurance company varies from one insurance company to another.  These numbers are ARBITRARY and are not supported by the peer reviewed plastic surgery literature.

Physical therapy will help.  Get documentation and a letter from your family physician (cc the letters to your insurance company).  Also, tell the insurance company that you will complain to the Insurance Commissioner and to your State Representative.

In addition, contact the Human Resources Dept. in your place of work with whom you receive your insurance benefits and complain about the insurance company's treatment to their beneficiaries.  Put your complaints in writing and also cc this letter to the insurance company.  If you personally speak with the insurance company, request to speak only to a Supervisor and document your conversation.

Good luck.

A:

Insurance coverage of breast reduction is based on each individual company's criteria, some of which may be arbitrary.  It is possible for you and your plastic surgeon to submit an appeal in case of an adverse determination, and sometimes their original decision may be reversed.  There is ample documentation including outcome studies to justify coverage of breast reduction, and minimum amount of weight resection should not be the only factor.

Olivia Hutchinson, M.D. - View Other Answers by this Doctor
New York, NY

A:

Your best option is to contact your insurance carrier regarding their appeal process.  In addition to filing an appeal with your insurer, check with your state's office of insurance to help ensure you know your legal appeal rights as dictated by the state.  In general, it may take a VERY long time, but persistance will pay.  As you file your appeal, be sure to reference the insurance carrier's written policies for breast reduction coverage.  Good luck!

A:

I cannot speak for your health care insurance but there are often times appeal processes, especially with cases of marked asymmetry.  I would suggest you request an appeal and have any other of your healthcare providers (your physical therapist and primary care physician) write a note as well in favor of your claim.

I wish you well.

Dr. Edwards

A:

It doesn't cost anything to appeal the decision for your breast reduction surgery.  Many times decisions can be reversed on appeal, as they are usually reviewed by a surgeon.  If you have your insurance through your employment, I would suggest seeing if the Human Resources Department will help you with your appeal.

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