Insurance Denied breasts stating WLS was cosmetic?

I am posting this in the insurance forum also.  I have Anthem BCBS, almost 6 years out from lap RNY, lost 150 and have maintained.

I am currently seeking  a corrective/reduction surgery for my breasts.  My PS submitted my preauthorization claim to my insurance (requesting mastopexy) and they came back with the correction/reduction is the result of a previous cosmetic surgery and that they will not cover it.  I have appealed and they have stuck to their decision.  I meet the requirements for reduction with documented neck and back pain over the past 2 years and hand problems but since like many i dont have any fat tissue there...the weight is very minimal.  But that is not why they declined me...

  I understand that some people seek WLS as a cosmetic self-pay procedure but mine was considered elective medically necessary and covered by my insurance (Tricare) at the time.   My current insurance also covers WLS as the only method to treat obesity. And I would have met their requirements to have the surgery.  How is it that they determined that my WLS was a cosmetic procedure?

Does their clinical policy bulletin for mastoplexy state that the condition must result from some medical issue (such as breast cancer, masectomy, etc.)?  If so, then you might be screwed.  If not, then you might have a shot.

I'd work my way through the appeals process.  I believe at some point it goes to an outside party to determine coverage.

Good luck!

Oh, and I'd include information about why your WLS was a medically necessary procedure....medical records showing your weight and any comorbidities you had....records showing the correction of those issues....letters from your MDs stating it was medically necessary, etc.

Sorry to be the bearer of bad news, but, this is a cosmetic surgery. Unless you can prove a functional impairment, it is cosmetic.   This is the requirements followed by most insurance companies:    services will be covered as reconstructive or excluded from coverage as cosmetic will require review of the following clinical information and documentation:

A.      Contemporaneous physician office notes with the history of the medical condition(s) requiring treatment or surgical intervention. This documentation must include ALL of the following: i.         Contemporaneous office notes from the original office visit for macromastia, describing the member’s chief complaint, history of the complaint and physical exam; and   ii.       Documentation from the notes that the member has macromastia, and that this condition is the primary etiology of the member’s functional impairment or impairments, which are specifically described. Macromastia, also referred to as hypermastia or gigantomastia, is defined as abnormally large breasts that are the primary etiology for the secondary symptoms B.      Results of objective studies and tests used to rule out orthopaedic, neurologic and/or rheumatologic causes of the functional impairment (e.g. physical exam, electromyography (EMG), x-ray or magnetic resonance imaging (MRI). When back or neck pain is the primary complaint, a formal and thorough back evaluation is required C.      High-quality color photographs that indicate macromastia. The patient should be standing, with brassiere removed, and photos should include front torso (from sternal notch to pubis) and left and right lateral views. The date taken and the service reference identification number (obtained at time of notification) or patient’s name and ID number must be documented on the photograph(s) D.      Treatment plan that must include proposed procedures and the expected outcome for the improvement of the functional impairment


Have your doctor review this information.  If it's a specific exclusion...then there is no way around it. if they are denying your surgery as cosmetic vs. reconstructive.....try the above documentation in your appeal and as long as you meet the criteria, you should be okay. 

Hope that helps.

Thanks for the advice... As I said, they are calling my gastric bypass cosmetic.  So in effect, they are saying that my breasts being large is the result of having had a cosmetic gastric bypass surgery.  HAHA...dont i wish that was the way it happened.  I have filed appeal and this is the result of the appeal.  The first submission was just an automatic decline stating it was a cosmetic procedure.  I have provided chiropractic records for the past 2 years, documentation of my surgery and medical necessity, and recommendation of reduction from my PC, Gyno, and breast specialist as I now have issues due to cramming them in a bra all the time...along with a personal statement and various research reports stating that the only way to correct is via surgery.

Yes ma'am.  My best advice is exhaust all your appeals.  Your denial letter will have your next step of appeal.  May be external review, maybe thru the Dept of Insurance in your state.  I would exhaust all levels of appeal and make sure to file with the Dept. of Insurance.  Unless your on an ASO (which means your employer pays for it's own claims) the Dept. of Insurance can step in on your behalf but they will only do it once you have exhausted all of your appeal rights.  Breast reduction is a hard one to prove its reconstructive and not cosmetic with ANY insurance.  I work in the appeals dept at United Health Care, and trust me, this is one of the MOST frequent appeals that I work on.  Just keep trying.  IF everything else fails, go to your employer group and explain that you need a plan that doesn't exclude breast reduction as cosmetic and if you work for an employer that is cool enough to switch plan or offer you cafeteria style insurance where you can add your own riders, you can get them to switch plans at the next plan year (some plans start over in the middle of the year, not all of them renew on January 1st.) and you can get your surgery when the plan changes over and not have to pay out of pocket.  it's not the insurance company...it's the plan that your employer group chose.  Employers get to pick from every plan covering every benefit, but, the more that they cover, the more the premiums are.  So, to regulate costs, they generally pick basic coverage plan unless they hear otherwise from their employees.  Good luck!

While it is unlikely that this will help you out with the BR, but there was a lady that had some success getting her surgery labeled as reconstructive and the ins had to pay for it.

http://www.obesityhelp.com/forums/VSG/4318392/Cali-PS-patien ts-The-DMHC-is-about-to-rule-in-my-favor/

But basically (from what I understood of it) it came down to the fact that her insurance company called Obesity a disease and the CA code required them to cover reconstructive surgery for a defect cause by a disease.

I have AETNA and they specifically state that Obesity is a health issue, but not classified as a disease, so the reconstructive angle didn't work for me LOL..  but I did get them to cover the panniculectomy on appeal though.

Do your research and document your issues.

Best of luck!

My pcp told me that incurance will look at the amount of tissue to be removed for a lift to count as a "reduction". My cup size was DDD before my lift and I'll probably be a B cup after swelling goes down, but no real tissue was removed, only skin, so it would never count as a reduction.

Laura

I had a reduction back in '96 and TRICARE paid for it (was a military spouse) . 

I did a quick search and their site says..

TRICARE does not cover cosmetic, reconstructive or plastic surgery related to

• Reduction mammoplasties (breast reductions), except in the case of significant pain due to large breasts

And here is a link to their policy on the surgery.  Look at the 'note' on section 3.1.

They based the decision for mine on the physical impairments I was having (cronic back pain, grooves in my shoulders, rashes underneath, hump protruding on my back).  The fact that the tissue had detached and they had become "pendulous (picture the comic Maxine - and that was me at 26 - they hung out from under short shirts  LOL) didn't really matter.  And this is before I had lost the weight.

I had recorded visits to chiropractor over a couple of years, and they photographed the dents.

I wore DDD's, but only because it was the largest I could find at the time and I spilled out of them.  They took off a total of 2.2kilos (about 5lbs) of tissue and left me as a C cup.

Well I went back to the PS today... He said there is no way he could call it a reduction as there is not enough skin and tissue there to make the weight.  So I guess I'm looking at 14K to pay for it.  I guess the good part is that I did argue my insurance again and they threw a clause of "corrective surgery following weight loss surgery" at me.  So in effect my surgery is whatever my doc and I choose to call it...(medically necessary)...As it is excluded from my policy based on previous weight loss surgery...not that it is cosmetic in nature.

I read somewhere that California is passing laws requiring insurance to cover the skin removals and not be able to exclude it from previous weight loss...More states need to get on that bandwagon...  I dont know about anyone else, but I am almost 6 years from my initial surgery, I did have a TT/hernia repair one year out.  But I lost half my weight (150 lbs) and I have maintained it.  I make my choices every day just like anyone else and it is really difficult to look at myself in the mirror and think that I look better now than I did at 300lbs.