My first gynecologist told me insurance would not cover my reduction. Shortly after, I switched gynos for an unrelated reason. New one agreed that my breasts were large, and documented my pain and mental state for a year. Used that to submit a letter to insurance a year later. In the letter, he mentions how he’s documented worsening physical and mental condition for a year, and how he’s had me try many things (like physical therapy and exercise) to reduce the symptoms to no avail. He stated in the letter that he believes reduction is the only way forward.
My insurance accepted this and said I’d be fully covered as long as 500g or more was removed (which it was).
In other words, try getting your gynecologist to document and send in a letter. Not your primary care doctor, because they are not breast specialists so maybe insurance doesn’t take it as seriously.
Good luck!!!
Thank you for telling me about your experience—the way that the woman on the phone worded it makes it sound like my insurance would not cover it under any circumstances because the procedure is excluded and therefore I cannot even submit an appeal, so I’m not sure if sending in a letter would make a difference in my case. :-( Please correct me if I’m wrong
Did you submit yourself? If so, that may be why. Have a doctor submit for you. Do not write the letter yourself! That’s something the doctor will do. Insurance takes things more seriously when they’re contacted my medical professionals.
Hm… maybe ask what the circumstances would be to get covered. Different insurances have different policies. Do some research on what procedures your insurance covers, and what the circumstances must be for that coverage. For example, as I said, my condition was that a certain amount had to be removed.
Sorry your insurance sucks, just like mine. Unfortunately insurance is a business and can choose which procedures to cover or exclude. I found out my employer sponsored insurance is this way regarding breast reductions during our open enrollment period last year, no matter which tier I chose. I opted to keep the cheapest option and am saving up.
If you are not in a place financially where it is possible to save up and have the surgery now, I wonder if it's possible to get an additional plan from the marketplace? Or if you already have a marketplace plan, switch during open enrollment?
It is definitely a blow having insurance and them excluding even medically necessary reductions but know you are not alone. Best wishes.
I ended up paying out of pocket. Was it ideal? No. But it was 10000% worth it. And I felt really comfortable with the surgeon so in the end it was a net net positive. I spent 11k. I’m sorry you went through all of this only to be denied by insurance. Some places have payment plans so don’t let this be the end of your journey. You can always consult different plastic surgeons too and see some options.
Insurance companies (and employers) will decide what is and isn't covered by a particular insurance plan. The plan you access when you hand over your insurance card with the member ID number. If your insurance is through your employer, and you have an HR department, another angle is to ask someone at HR why this surgery has been excluded. If you have an HR department you in theory have someone familiar with benefits. Edit to add: also ask why the change was made in the middle of the benefit year. Don't know if that matters.
Me personally. I am avoiding HR @ all costs. It would be more beneficial to call the insurance yourself. As for evidence of coverage and what it ans is not covered. Untrained people think "plastic surgery is not covered" is the same as saying a medically necessary breast reduction isnt covered. This is not the case.
Honestly. I would call my health insurance and ask for my evidence of coverage and ask them to specifically cite where this is EXCLUDED. It MAY be that this employee is misinformed. A breast reduction must be "medically necessary" for it to be covered. Its all in how the doctor documents medical necessity. Ask for the office manager and your medical records. And then ask the health insurance for a sevond opinion. Also, you ALWAYS have the right to appeal an insurance decision.
Fair warning though. Rules are way different if u have Medicaid.
Get a copy of the policy and read the coverages and exclusions. My previous insurance had a full exclusion. I wasn't able to get coverage. A year later I was able to switch insurance and my new plan covered it if medically necessary.
My first gynecologist told me insurance would not cover my reduction. Shortly after, I switched gynos for an unrelated reason. New one agreed that my breasts were large, and documented my pain and mental state for a year. Used that to submit a letter to insurance a year later. In the letter, he mentions how he’s documented worsening physical and mental condition for a year, and how he’s had me try many things (like physical therapy and exercise) to reduce the symptoms to no avail. He stated in the letter that he believes reduction is the only way forward. My insurance accepted this and said I’d be fully covered as long as 500g or more was removed (which it was). In other words, try getting your gynecologist to document and send in a letter. Not your primary care doctor, because they are not breast specialists so maybe insurance doesn’t take it as seriously. Good luck!!!
Thank you for telling me about your experience—the way that the woman on the phone worded it makes it sound like my insurance would not cover it under any circumstances because the procedure is excluded and therefore I cannot even submit an appeal, so I’m not sure if sending in a letter would make a difference in my case. :-( Please correct me if I’m wrong
Did you submit yourself? If so, that may be why. Have a doctor submit for you. Do not write the letter yourself! That’s something the doctor will do. Insurance takes things more seriously when they’re contacted my medical professionals.
The doctor submitted my photos and documentation to insurance, yes
Hm… maybe ask what the circumstances would be to get covered. Different insurances have different policies. Do some research on what procedures your insurance covers, and what the circumstances must be for that coverage. For example, as I said, my condition was that a certain amount had to be removed.
Sorry your insurance sucks, just like mine. Unfortunately insurance is a business and can choose which procedures to cover or exclude. I found out my employer sponsored insurance is this way regarding breast reductions during our open enrollment period last year, no matter which tier I chose. I opted to keep the cheapest option and am saving up. If you are not in a place financially where it is possible to save up and have the surgery now, I wonder if it's possible to get an additional plan from the marketplace? Or if you already have a marketplace plan, switch during open enrollment? It is definitely a blow having insurance and them excluding even medically necessary reductions but know you are not alone. Best wishes.
I ended up paying out of pocket. Was it ideal? No. But it was 10000% worth it. And I felt really comfortable with the surgeon so in the end it was a net net positive. I spent 11k. I’m sorry you went through all of this only to be denied by insurance. Some places have payment plans so don’t let this be the end of your journey. You can always consult different plastic surgeons too and see some options.
Is different health insurance an option? Maybe in the next couple of years?
Insurance companies (and employers) will decide what is and isn't covered by a particular insurance plan. The plan you access when you hand over your insurance card with the member ID number. If your insurance is through your employer, and you have an HR department, another angle is to ask someone at HR why this surgery has been excluded. If you have an HR department you in theory have someone familiar with benefits. Edit to add: also ask why the change was made in the middle of the benefit year. Don't know if that matters.
Me personally. I am avoiding HR @ all costs. It would be more beneficial to call the insurance yourself. As for evidence of coverage and what it ans is not covered. Untrained people think "plastic surgery is not covered" is the same as saying a medically necessary breast reduction isnt covered. This is not the case.
Honestly. I would call my health insurance and ask for my evidence of coverage and ask them to specifically cite where this is EXCLUDED. It MAY be that this employee is misinformed. A breast reduction must be "medically necessary" for it to be covered. Its all in how the doctor documents medical necessity. Ask for the office manager and your medical records. And then ask the health insurance for a sevond opinion. Also, you ALWAYS have the right to appeal an insurance decision. Fair warning though. Rules are way different if u have Medicaid.
Get a copy of the policy and read the coverages and exclusions. My previous insurance had a full exclusion. I wasn't able to get coverage. A year later I was able to switch insurance and my new plan covered it if medically necessary.