breast reduction scheduled but finding drama
I saw a plastic surgeon on July 21st. I have always had large breasts but it seems that since RNY my back and neck are hurting so much more than ever before and as I am losing weight it's not going down in my breasts!
My insurance changes at the first of September and the insurance I have now is a wonderful one. It will cover breast reduction as long as 375 cc is removed from each breast and it's medically necessary. My out of pocket is zero for this procedure. My next insurance is so crappy I don't think they would even pay for it so I am going for it now even though I am not done losing all my weight. My surgeon agreed that she felt it was ok to do it now.
They took photos my breasts, said they had to turn it in to my insurance to get approval. I have been hounding the insurance company for a week now asking if they have received the pre approval documents and photos because I am scheduled for the 26th and if that date gets messed up there is no rescheduling (I of course am not telling them I am going off cobra at the end of the month, that would give them excuse to drag their feet)
I have also been calling the person at the Mayo Clinic making sure she really sent the info, did she get any news etc. I know I am driving them crazy but I really want this!
Finally today I talked to the "right person" at BC/BS of Mass she tells me that a pre approval is not needed for my plan as long as I meet the criteria, that mine is not managed care, it's a PPO and so I don't need approval.
Wonderful I thought! So I rang the woman at Mayo to tell her I really don't need pre-approval and that we are good to go. "Not so fast" she says. She informs me that BC/BS is half way correct, I don't need pre-approval but she wasn't going for pre-approval she was wanting them to tell her that it was medically necessary based off what the surgeon said and the photos she sent. She said she wants them to say it that way later on they cant say it wasn't medically necessary.
Is this the run around? I am at a loss and not sure if what she says is correct. The woman at BC/BS of Mass today made it sound as if it was fine and to go ahead with it.
I'm confused now. Will BC/BS even tell them they think it's medically necessary? What is the norm here?
My insurance changes at the first of September and the insurance I have now is a wonderful one. It will cover breast reduction as long as 375 cc is removed from each breast and it's medically necessary. My out of pocket is zero for this procedure. My next insurance is so crappy I don't think they would even pay for it so I am going for it now even though I am not done losing all my weight. My surgeon agreed that she felt it was ok to do it now.
They took photos my breasts, said they had to turn it in to my insurance to get approval. I have been hounding the insurance company for a week now asking if they have received the pre approval documents and photos because I am scheduled for the 26th and if that date gets messed up there is no rescheduling (I of course am not telling them I am going off cobra at the end of the month, that would give them excuse to drag their feet)
I have also been calling the person at the Mayo Clinic making sure she really sent the info, did she get any news etc. I know I am driving them crazy but I really want this!
Finally today I talked to the "right person" at BC/BS of Mass she tells me that a pre approval is not needed for my plan as long as I meet the criteria, that mine is not managed care, it's a PPO and so I don't need approval.
Wonderful I thought! So I rang the woman at Mayo to tell her I really don't need pre-approval and that we are good to go. "Not so fast" she says. She informs me that BC/BS is half way correct, I don't need pre-approval but she wasn't going for pre-approval she was wanting them to tell her that it was medically necessary based off what the surgeon said and the photos she sent. She said she wants them to say it that way later on they cant say it wasn't medically necessary.
Is this the run around? I am at a loss and not sure if what she says is correct. The woman at BC/BS of Mass today made it sound as if it was fine and to go ahead with it.
I'm confused now. Will BC/BS even tell them they think it's medically necessary? What is the norm here?
10 pounds loss pre-op
I work in a billing department and see stuff alllll the time! If they say Pre Approval is not needed that just means you don't need an authorization number for the procedure. The doctor can go ahead and do the surgery, but it doesn't mean it is covered. If the surgery is done and the insurance decides based upon medical records that the surgery is not "Medically Necessary" then you would be responsible for the entire bill or whatever part they decide to not cover!! That is why they want it to be medically necessary. Does that make sense?
Yes, it makes sense. What would they think isn't medically necessary.
They are going to remove 500cc out of one breast and 750cc out of the other (the requirements is 375cc so this is quite a bit more than that)
I have documented back and shoulder pain when I saw the chiropractor last April.
So, in your experience then will BC/BS actually say "Yes, we feel it's medically necessary" or will they just continue with this "wait and see" game.
I'm very uncomfortable with having a surgery not knowing whether or not it's going to be paid for so I can understand what the Mayo person is doing, will she get a concrete answer from BC/BS of Mass?
They are going to remove 500cc out of one breast and 750cc out of the other (the requirements is 375cc so this is quite a bit more than that)
I have documented back and shoulder pain when I saw the chiropractor last April.
So, in your experience then will BC/BS actually say "Yes, we feel it's medically necessary" or will they just continue with this "wait and see" game.
I'm very uncomfortable with having a surgery not knowing whether or not it's going to be paid for so I can understand what the Mayo person is doing, will she get a concrete answer from BC/BS of Mass?
10 pounds loss pre-op
well I know someone that happened to ,they said she didn't need pre-approval and then BC didn't cover it & she was responsible for it, when you go in the hospital they make you sign a paper that you are responsible, if you are on cobra can't you just pay for it another month to be sure, personally I wouldn't do anything until I received the letter that said approved. What we think is medically necessary insurance companies don't.
Good Luck with your approval
Good Luck with your approval
it's my husband's cobra plan. I dont know if I can do it on my own for one month. Since insurance is offered at his new company starting September 1 we are going there and we dont get the reduced rate on Cobra. Currenly we were paying $670 per month for the plan. Once insurance is offered at a different place it goes to $1900 per month. I dont know if they'd allow me to stay for one month and not the rest of the family since it's my husbands plan.
10 pounds loss pre-op
I also have BC/BS Mass PPO. Both my daughters had a breast reduction on my insurance plan. Less than three weeks after their consultation appointment BC/BS sent me a letter stating that the breast reduction was approved and no overnight stay. I am going to consult with two PS for possibly get a breast reduction. Good Luck!
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