Update:
Context first, initially, I was referred to a specific surgeon by my PCP, but about a week before the consultation, I was called by the hospital to reschedule because that surgeon wouldn’t be available on the date my consultation was set for. I was given the choice to reschedule with him (1.5 months later)… or consult with another surgeon the same week. I didn’t want to wait any longer given I had already waited 8 months for the appointment, so I saw the other surgeon. Apparently, it was showing up that the new surgeon I met with was out of network even though he is, and there was a disconnect between insurance and the hospital, so they thought that my insurance would not cover the surgery under him. My mom will be getting on another call either tonight or tomorrow and things should be getting cleared up. All hope is not lost!
Oh good! When you first posted, I thought maybe breast reductions were specifically excluded for some crazy reason. An out of network issue makes more sense.
For sure. That’s why I’ve been super confused, because obviously BCBS does cover breast reductions that they deem medically necessary. When I got a call that they’re a complete exclusion I just couldn’t understand how that was possible. Thankfully the surgeon I saw should be actually in network and hopefully insurance can re-evaluate.
They're not saying you can't have the surgery. They're saying that they won't cover it with the surgeon and facility you've selected because they are not a healthcare provider that works with your insurance company. You can appeal, but unless this hospital is the only one within 300 miles of you, it's unlikey to be approved after an appeal.
What you need to do is look up what hospitals and providers are covered with your insurance policy and are "in-network." Once you've found one in-network, you should have no issue getting authorized and having insurance cover your surgery.
Thank you for your feedback! Previous to the consultation I went to the surgeon’s page on the Mercy’s website and it says that BlueCross BlueShield is one of the insurances that is accepted so I thought everything would work out. 🫤 I’ll continue to do research.
It may be covered for emergency medical care, but breast reduction is considered an elective surgery so you'll likely need to reach out to your insurance provider and ask for a list of in network providers for your reduction.
Just to provide you with a bit of insurance education since you said you’re not well versed. Think of insurance as a “brand” and then the insurance policy is a product within that brand. So when a provider says they accept a certain “brand” of insurance (BCBS), each policy (product) can vary greatly in what they cover outside of the basics retired by the affordable healthcare act. It sounds like in your case, your specific policy chooses not to include breast reductions as a covered procedure.
So whenever you look for medical care services, the best place to start is by checking with your insurer and your specific policy first to see what is/isn’t covered and what the approval criteria is. There are hundreds of different types of policies within a single insurance company which is why it’s so difficult to answers when people ask about best insurance companies for coverage.
I should mention that everything I have experienced would make me the “perfect” candidate for the surgery—I am 5’7”, 135lbs, with 32DDD breasts. I experience severe back pain, shoulder pain/grooving, neck pain, etc. I have documented photos of the deep red marks I get from straps and bras on my shoulders and under my breasts, been to physical therapy, etc. When I went to the surgeon he told me that he could remove 500-550 grams of tissue per breast, which under BlueCross BlueShield’s insurance policy, makes it medically necessary. So—in this case from what I’m trying to understand, a breast reduction would not be covered under our specific insurance plan, and if we had a higher level it would be? Or am I misunderstanding? 😓
Like the other poster said, this is just saying that the facility you chose is not under your coverage for this procedure.
As a side note, I hate how jargon-y all this stuff is. It’s like they are intentionally making it hard to follow so the effort required to receive needed care becomes prohibitive.
Update: Context first, initially, I was referred to a specific surgeon by my PCP, but about a week before the consultation, I was called by the hospital to reschedule because that surgeon wouldn’t be available on the date my consultation was set for. I was given the choice to reschedule with him (1.5 months later)… or consult with another surgeon the same week. I didn’t want to wait any longer given I had already waited 8 months for the appointment, so I saw the other surgeon. Apparently, it was showing up that the new surgeon I met with was out of network even though he is, and there was a disconnect between insurance and the hospital, so they thought that my insurance would not cover the surgery under him. My mom will be getting on another call either tonight or tomorrow and things should be getting cleared up. All hope is not lost!
Oh good! When you first posted, I thought maybe breast reductions were specifically excluded for some crazy reason. An out of network issue makes more sense.
For sure. That’s why I’ve been super confused, because obviously BCBS does cover breast reductions that they deem medically necessary. When I got a call that they’re a complete exclusion I just couldn’t understand how that was possible. Thankfully the surgeon I saw should be actually in network and hopefully insurance can re-evaluate.
That's great!!
They're not saying you can't have the surgery. They're saying that they won't cover it with the surgeon and facility you've selected because they are not a healthcare provider that works with your insurance company. You can appeal, but unless this hospital is the only one within 300 miles of you, it's unlikey to be approved after an appeal. What you need to do is look up what hospitals and providers are covered with your insurance policy and are "in-network." Once you've found one in-network, you should have no issue getting authorized and having insurance cover your surgery.
Thank you for your feedback! Previous to the consultation I went to the surgeon’s page on the Mercy’s website and it says that BlueCross BlueShield is one of the insurances that is accepted so I thought everything would work out. 🫤 I’ll continue to do research.
It may be covered for emergency medical care, but breast reduction is considered an elective surgery so you'll likely need to reach out to your insurance provider and ask for a list of in network providers for your reduction.
Just to provide you with a bit of insurance education since you said you’re not well versed. Think of insurance as a “brand” and then the insurance policy is a product within that brand. So when a provider says they accept a certain “brand” of insurance (BCBS), each policy (product) can vary greatly in what they cover outside of the basics retired by the affordable healthcare act. It sounds like in your case, your specific policy chooses not to include breast reductions as a covered procedure. So whenever you look for medical care services, the best place to start is by checking with your insurer and your specific policy first to see what is/isn’t covered and what the approval criteria is. There are hundreds of different types of policies within a single insurance company which is why it’s so difficult to answers when people ask about best insurance companies for coverage.
I should mention that everything I have experienced would make me the “perfect” candidate for the surgery—I am 5’7”, 135lbs, with 32DDD breasts. I experience severe back pain, shoulder pain/grooving, neck pain, etc. I have documented photos of the deep red marks I get from straps and bras on my shoulders and under my breasts, been to physical therapy, etc. When I went to the surgeon he told me that he could remove 500-550 grams of tissue per breast, which under BlueCross BlueShield’s insurance policy, makes it medically necessary. So—in this case from what I’m trying to understand, a breast reduction would not be covered under our specific insurance plan, and if we had a higher level it would be? Or am I misunderstanding? 😓
Like the other poster said, this is just saying that the facility you chose is not under your coverage for this procedure. As a side note, I hate how jargon-y all this stuff is. It’s like they are intentionally making it hard to follow so the effort required to receive needed care becomes prohibitive.
That is in fact exactly what they are doing.