Cosmetic Surgery Tips

How To Appeal A Breast Reduction Denial

One of the first questions women seeking a breast reduction surgery will ask is “Who will pay for breast reduction?” The good news is that these days, most insurance companies cover breast reduction surgery when it is deemed medically necessary. Since many of our patients come to Dr. Golshani with substantial physical complaints due to their breast size, most of these patients have been able to get insurance to cover their surgery costs. Dr. Golshani works with a experienced Insurance Specialist in Los Angeles who will help you understand the decision-making process, provide you with advice, and walk you through this step-by-step in order to maximize the chances of your insurance company paying for the surgery. Let’s cover a few things you should know about getting insurance coverage for surgery to reduce breast size.

This guide also outlines how to appeal insurance claim denial and appeal denial letter sample.

How To Appeal A Breast Reduction Denial

If you get a denial and feel that breast reduction is necessary for your health and well-being, you are legally entitled to appeal. The appeals process should be described in the denial letter. In most cases, multiple levels of appeal are available, and you should take advantage of them. Letters from a family doctor, orthopedist, physical therapist, chiropractor, or massage therapist can help support an appeal. You should write your own letter describing your symptoms and how they have limited your life (focus on your physical problems rather than your difficulty finding a bathing suit). Ask your doctor to submit your personal letter, supporting letters, up-to-date scientific information about the standard of care for treating symptomatic macromastia and a list of medical literature references with the appeal.

Insurance policy exclusions

Cosmetic procedures that help to improve someone’s appearance and even procedures that insurance companies feel could be treated with nonsurgical methods are usually denied coverage. There are still a few insurers that believe that breast reduction is actually a cosmetic “breast lift” operation and that large breasts can be treated with weight loss. Thus, they may refuse coverage for women seeking this procedure. In addition, breast reduction surgery can sometimes be included on a health insurance policy’s list of coverage exclusions. Most commonly, this is seen in managed-care plans such as HMOs. Yet, there has been growing medical evidence in recent years that breast reduction surgery is a medical requirement and can assist a woman’s physical and mental wellbeing. Even those insurance companies that do not cover breast reduction are starting to pay attention.

Insurance coverage: process

It is common for health insurance companies to individually review cases and use established criteria in determining whether or not to cover a breast reduction surgery. Criteria commonly used to evaluate coverage include:

  • Estimated weight of tissue to be removed from each breast, which often ranges from 300 to 800 grams per breast
  • Bra cup size (Insurers usually require that breast reduction patients wear a C cup or larger)
  • Patient’s percentile on the Schnur scale (Based on the patient’s body surface area and estimate weight of breast tissue to be surgically removed)
  • Body weight and/or body mass index (BMI)
  • Physical symptoms of large breasts including shoulder grooving, skin problems and deformity
  • Other documentation of nonsurgical treatment(s) failure including weight loss, supportive bras, medications and physical therapy
  • Photographs

Even if your insurance plan covers the surgery, you must meet their specific, written criteria and this can be a simple, straightforward process or a very difficult one. For example, for overweight patients, insurance companies may sometimes require significant weight loss to reduce body mass index below 30 before they authorize surgery. Therefore, weight loss or documentation of failed attempts of weight loss is often a significant requirement. In addition, insurers usually assign more value to specific criteria and symptoms.

How the insurance process works for reducing breast size surgery

Insurance companies require authorization before surgery, even if all criteria for coverage is met. Without prior authorization, they may not be obligated to pay for anything. To request this approval of coverage, our Insurance Specialists will write a letter to your insurance company detailing relevant medical information as well as an estimate of how much weight will be removed from each breast. Along with this formal request, photographs of your breasts taken during your consultation and insurance forms will be included in the preauthorization package.To expedite this process, it will be helpful if you bring the following documentation to your initial consultation:

  • Current insurance card
  • Valid driver’s license or photo ID
  • Pre-authorization or letter of referral from primary treating physician
  • Evidence of previous conservative care such as weight loss or physical therapy

It may take several weeks for insurance companies to respond. If approved, it is important to get the approval in writing and to thoroughly understand what conditions have been placed on the coverage as well as your financial liabilities.

What to do if insurance denies your breast reduction surgery

There are several reasons an insurance company may deny coverage for a breast reduction surgery including policy exclusion and the lack of information provided to meet criteria. Health insurance denial can be frustrating but do not give up hope. Denials happens, and in this case, Dr. Golshani’s team will work with you to legally appeal the decision and help you to implement the following action plan:

  1. After studying the reasons for denial, file an appeal with the insurance company or in the case of policy exclusions, with your state department of insurance (some states even mandate breast reduction coverage for women who fit criteria).
  2. Provide more information which may include a detailed letter written by you describing your symptoms and physical limitations and supporting letters from other physicians or therapists.
  3. Wait…insurance companies usually respond four to six weeks after the appeal is filed.

Keep in mind that you have the legal right to do so and that you should make the most of it. There is a greater probability of success the more dedicated you are. Many people have had their insurance pay for their breast reduction after successfully appealing a denial.

How To Appeal Insurance Claim Denial

There are two ways to appeal the denial of a health insurance claim: an internal review appeal and an external review appeal.

Internal review

An internal review appeal, also called a “grievance procedure,” is a request for your insurer to review and reconsider its decision to deny coverage for your claim. You have a right to file an internal appeal. By doing so, you’re asking your insurer to conduct a fair and complete review of its decision.

External review

If your insurer continues to deny coverage for a disputed claim, you have the right to pursue an external review appeal. An independent third party performs this. It’s called “external” because your insurer will no longer have the final decision over whether or not to pay for a claim.

Steps Involved With Appealing a Health Insurance Claim Denial

Step 1: Find out why the claim was denied

If you received notification from your insurer that your claim was denied, read through the correspondence carefully, including any Explanation of Benefits provided.

Your insurer is legally required to notify you in writing and explain why your claim was denied within 15 days if you’re seeking prior authorization for a treatment, within 30 days for medical services already received or within 72 hours for matters of urgent care.

If the explanation isn’t satisfactory or unclear, try contacting your insurer and learning more. Carefully document any communication with your insurance.

Step 2: Ask your doctor for help

Contact your physician’s office and ask why they believe your insurer denied your claim. It might simply be an issue like the provider office entered the wrong payment code.

Ask them to verify that the treatment or service provided was medically necessary and that the appropriate medical code was submitted to the insurer. Document anything you learn.

Gather documentation from your provider, including health records, dates, a copy of the claim form they submitted and possibly a fresh letter from your doctor requesting that the claim be accepted based on their assessment of the situation.

Step 3: Learn how and when to appeal

Review your health insurance policy, which should indicate the steps required for appealing, the deadlines to file an appeal and how and where to submit the appeal. Phone or email your insurer if you lack this paperwork.

Step 4: Write and file an internal appeal letter

Compose an appeal letter with all the pertinent facts, details and substantiation needed to defend your claim. Be as factual, concise and respectful as possible. Don’t be threatening, hostile or abusive in your words or tone.

Step 5: Check back with your health insurance company

Review your policy regarding how long you can expect to wait before your insurer reviews and issues a decision on your appeal. After that time has passed, or if in doubt, contact your insurance company to check your appeal’s status.

Step 6: File an external review appeal if necessary

If your internal review appeal has been denied and your claim remains unapproved, consider filing an external review appeal. This must be filed within four months following the date you received a final determination or notice from your insurer that your claim was denied.

Ask your insurer how to officially file an external review.

Step 7: Contact with your state

If you’ve exhausted the appeal process with the insurer, contact your state’s department of insurance, attorney general’s office or office of consumer affairs. States can help you with an external review of the claim denial.

Appeal Denial Letter Sample

Name of Agency Official
Appeals Officer
Name of Agency
Address of Agency
City, NY, ZIP code

            Re: Freedom of Information
              Law Appeal
Dear __________:
    I hereby appeal the denial of access regarding my request, which was made on __________ (date) and sent to __________ (records access officer, name and address of agency). 
    The records that were denied include:_______________ (describe the records that were denied to the extent possible and, if possible, offer reasons for disagreeing with the denial, i.e., by attaching an opinion of the Committee on Open Government acquired for its website). 
    As required by the Freedom of Information Law, the head or governing body of an agency, or whomever is designated to determine appeals, is required to respond within 10 business days of the receipt of an appeal. If the records are denied on appeal, please explain the reasons for the denial fully in writing as required by law.
    In addition, please be advised that the Freedom of Information Law directs agencies to sendall appeals and the determinations that follow to the Committee on Open Government, Department of State, One Commerce Plaza, 99 Washington Ave., Albany, New York 12231.

           City, State, ZIP code

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