If you’re wondering how to get a breast reduction covered by your insurance plan‚ you’re not alone. There are a few things you need to know before you submit your claim‚ including pre-authorization‚ documentation‚ and medical necessity. If you are denied coverage‚ you can appeal the decision.
Pre-authorization
Pre-authorization is required by most insurance companies before you can receive surgery‚ including breast reduction. Without it‚ your insurance company may refuse to cover your procedure. To get approved‚ you must provide your insurer with medical records that show your breast reduction is medically necessary and has been deemed safe for you. Often‚ the records should date back at least six months. Your OB/GYN should provide notes as well. Documentation of complementary medicine treatments may also be necessary.
Some insurance companies may require pre-authorization of the procedure for a variety of reasons. Common reasons include out-of-network physicians‚ failure to meet carrier guidelines‚ and spotty documentation. The amount of tissue to be removed and how much it weighs will vary among plans‚ so be sure to ask about pre-authorization requirements before scheduling your appointment.
If you’re considering a breast reduction surgery‚ contact a plastic surgeon who specializes in the procedure. He or she can write a letter of medical necessity detailing the reasons for your surgery and the extent of your medical condition. Be sure to mention any prior back pain or neck issues‚ or other medical conditions you may have that warrant a reduction. Also‚ be sure to specify the amount of grams that will be removed from each breast – this is an important parameter for the insurance company to consider.
Documentation
When submitting your claim for insurance coverage for a breast reduction‚ you need to have documentation to prove the necessity of the surgery. This documentation can be in the form of photos of your pre-operative breasts or notes from your doctor describing your symptoms. The insurance company will need to review this documentation and determine whether the procedure is medically necessary.
Your insurance company will require a note from your plastic surgeon stating that you need the surgery for medical reasons and that the procedure will decrease your bust size. This note must be submitted to your insurance carrier along with any supporting letters from other healthcare providers. If your request is denied‚ you can file a grievance with your insurance carrier and ask them to reprocess your bills.
If you have chronic health problems that prevent you from wearing your bra‚ it may be difficult to get insurance coverage for a breast reduction. Although many insurers will cover the procedure if you have a serious medical problem‚ the insurance company must be convinced that it is medically necessary in order to give you full coverage. The insurance company will often require photographic documentation of your breast hypertrophy‚ which can be done during your consultation with your plastic surgeon.
Medical necessity
A breast reduction is a surgical procedure that reduces the size of the breasts. The procedure is commonly performed for cosmetic reasons‚ but can also be required for health reasons. Insurance companies will typically cover the cost of breast reduction procedures if they are deemed “medically necessary” for a specific condition. The specific requirements for medical necessity vary from insurer to insurer. It is best to contact your insurance company and ask about their guidelines.
Some reasons for medical necessity include pain in the back‚ neck‚ or shoulder caused by oversized breasts. The procedure can help alleviate these symptoms. Overweight breasts can cause rashes and may limit a person’s ability to move or sleep‚ as well as restrict their ability to participate in physical activity. Excessive breast tissue may also lead to an abnormal curvature of the spine‚ known as kyphosis. This can lead to back pain‚ stiffness‚ and paresthesias in the upper extremities.
Insurance companies require a pre-authorization letter from a surgeon before covering the procedure. This letter will include photographs of the breasts taken during a consultation. A copy of the preauthorization package will also contain any insurance forms that need to be completed before surgery can proceed. It may take several weeks before the insurance company responds to your request. In the meantime‚ it is important to receive a written authorization before surgery. It is also important to understand the conditions of coverage and financial liability.
Appealing denial of coverage
If your insurance company has denied coverage for a breast reduction‚ you can appeal the decision. Your denial letter should explain how to do so. You should write to the insurance company explaining why you should be covered and requesting that they have a board-certified plastic surgeon review the decision.
Before you write to your insurer‚ make sure you have all of the necessary documentation for the claim. The company will want to see that the breast reduction is medically necessary. Most insurers will have strict requirements regarding the amount of breast tissue removed. Make sure to ask about these before you begin your procedure‚ or you may be surprised with an unexpected bill.
You can also contact your doctor’s office to ask them to send a letter to the insurance company on your behalf. This letter should explain the medical necessity of the procedure‚ and should go to the address listed in your plan’s appeals process. Often‚ insurance companies will be more accommodating if you submit the proper paperwork for your claim.
