INSURANCE COVERAGE FOR BREAST REDCUTION
One of the first questions women seeking a breast reduction surgery will ask is “Who will pay for the surgery? Who will pay the bill?” Unless you are already planning to pay for the surgery’s expenses out of pocket, answering this question is one of the most important things you’ll need to do. Yes, this may seem like a daunting, complicated task, one you may want to push under the rug and wait to answer, but without understanding what your insurance will cover, you may end up with unexpected and significant out-of-pocket expenses, including a co-pay or deductible!
||Not to worry...Avosant Surgical Associates and our experienced Insurance Specialists will help you tackle this issue, provide you with advice and walk you through this step-by-step process in order to maximize the chances of your insurance company paying for the surgery. Before we work with you to make the process a more positive and easier experience, there are several things you should know...
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. Few insurers 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. However, in recent years, there has been increasing hard medical evidence that breast reduction surgery is a medical necessity and can help to improve the physical and psychological health of a woman and insurance companies, even those excluding coverage of breast reduction, are beginning to take note.
THE PROCESS OF MEETING INSURANCE CRITERIA
It is more 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 can range from 300 to 800 grams per breast or even more
- Bra cup size (Insurers usually require potential patients to 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)
- Symptoms caused by excessive breast weight and not other conditions
- Physical signs (Includes large breasts, shoulder grooving, skin problems and deformity or asymmetry cause by breast cancer)
- Other documentation of nonsurgical treatment(s) failure (Including weight loss, supportive bras, medications and physical therapy)
||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.
Avosant will provide you with much support but it will also be necessary for you to make a contributable effort in order to be successful. With your cooperation and help, we will assist you with the preparation of your insurance forms, claims and payment issues in order to efficiently use the time to concentrate on caring for your medical needs.
Here’s how the process works...
Insurance companies require authorization BEFORE THE 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:
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.
- 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
WHAT IF YOUR BREAST REDUCTION COVERAGE IS DENIED?
There are several main reasons why 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! Avosant 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. Remember that it is you legal right to file an appeal and you should take full advantage of the appeal process. The more you are committed, the more there is a chance for success!
Other Available Financing Options
Avosant Surgical Associates also offers other types of financing options including one of the leading patient financing programs, CareCredit. With a simple application, you can apply for a personal line of credit for your breast reduction surgery. There are no up-front costs and no annual fees. Just select the extended payment plan that works for you and pay a minimum monthly payment with low, fixed interest rates.
Avosant will also work with you if your primary insurance is a managed-care Medicare or Medicaid plan. A social insurance program funded by the federal government, Medicare provides health insurance to individuals who are aged 65 or over, or who meet certain criteria while Medicaid is a needs-based social insurance program funded by the state and federal government. It pays for medical assistance for those with low income and financial resources. Our Insurance Specialists will help you to obtain a predetermination review for payment of your breast reduction surgery.
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