Question:
Has anyone had their insurance cover a mastopexy without a reduction

I have select blue bc/bs western pa.... i had gone to a surgeon and was approved for a reduction&lift, which was not what he told me he would apply for, he said a reconstructive mastopexy.. im sure you could imagine my anger when i found out i couldnt have the surgery, b/c he messed up, he told me that after further looking he realized i didnt have enough tissue for a reduction. whic he told me that b4 he applied, now im at my whits end, denied 2 times for a panni, which he applied for too but as an adominalplasty, which wasnt what he told me he was applying for either! Sorry for venting, I was told that NO INSURANCE covers a LIFT, which i know isnt true, ive seen people who have had it covered. PLEASE someone give me some hope to go on and try again for these surgeries. I have been diagnoses with DDD, my hips are unalined and wont stay in place , ive got the whole side of my right leg which is numb and has been for 9 months, (im 1 1/2 yrs Post-op) chronic baack pain and not to mention the chest wall and neck/shoulder pain and headaches from my breasts. My mental state is at its all time low, I know there are ppl out there who need these surgeries way more then i do,so i know i shouldnt whine! But how does one live life suffering as much as they did heavy?! Any help will be appreciated. Brandy email me at [email protected] ... ha that should be jstsodamsaggy instead.    — brandy H. (posted on April 22, 2004)

April 22, 2004
Brandy, I think you need to drag out YOUR plan summary and see what it covers and excludes. You can't do anything about what other insurance plans do and do not cover! The only thing to be concerned about is what your plan covers. If you didn't do your homework and find out your plan's criteria for reconstructive surgery, then don't blame the surgeon. It is impossible for him to know what every plan covers for every person who comes to him. He probably did his best to get the insurance company to cover your surgeries, but they didn't buy it. If he applied for an abdominoplasty, he did try to get a more reconstructive type of surgery covered, rather than a panniculectomy, which just about every plan out there considers cosmetic. I feel your pain - I am in the process of trying to get an abdominoplasty covered because of the functional problems I am having. My particular policy says "Panniculectomies and similiar surgeries are not covered after WLS". It also says that "reconstructive procedures are covered after surgery to change size, shape or appearance,(and WLS is covered as an exception to the non-coverage of surgeries to change size shape or appearance), if the first surgery was approved by the plan, and the second surgery is to correct a significant functional defect". You have to be an advocate for yourself and figure out how you can make the system work for you. My original request from the plastic surgeon was denied in a heart beat, but once MY letter went in, it is now being reconsidered. Help yourself and don't blame the surgeon.
   — koogy

April 22, 2004
No insurance covers a lift, is true, however that is for "normal" cases. All insurances have to "review for medical necessity" this means to reconstruct or for medical reasons vs cosmetic. My lift was covered, as it was deemed a medical necessity. I had all of the same symptoms of hanging breasts that a very large breast has. Back pain, neck pain, rash under breast,unable to exercise due to floppy skin, etc. My doctor wrote "She doesn't want them any bigger or smaller, just back where they belong" It was covered the first time. I did medical review for a huge company doing this type of "physical enhancement". There is certain procedures that automatically need a review to determine that this is a "medical necessity" vs cosmetic. This is one of them. Remember always appeal if denied. Best of luck!
   — ZZ S.

April 22, 2004
Believe it or not, my insurance federal bc/bs paid for my breast lift. I didn't get a reduction in fact I had implants put in. I personally think it got passed them somehow or they saw the pictures and took pity on me. I told my doctor to submit everything and what they didn't pay for, I would pay for. He did and they paid for it. I was prepared to pay for it myself and was not going to appeal it if it was denied. The strange thing was my abdominoplasty was denied even though I had a hernia. I appealed it and it was still denied, so I ended up paying only the surgeon's portion of that. My insurance took care of everything else, ie., hospital fees, anesthesia, because of the hernia.
   — Lisa N M.

April 22, 2004
I should also add that the best criteria for a breast lift would be rashes under your breast. If you are getting them lifted that is not going to do anything with the weight of them if you are not getting a reduction.
   — Lisa N M.

April 23, 2004
Susan K i was blaming the surgeon for telling me one thing then applying for something i didnt need IE a reduction. When i walked out of that office after my consult after he had told me I DONT HAVE ANY BREAST TISSUE, he told he he was applying for a panni--(you know ) and a reconstructive breast lift, i made sure i asked exactly what it was he was applying for b/c i knew an adominalplasty would not be cover plus i didnt need that done. That is all i am blaming him for. And i am sure if you were with me at my appointments, you would agree he wasnt a dr with a good bedside manner nor knew whAT was going on, his staff wanted to take pics for me to send in top the insurance company, after she said that i said for what im already approved . So needless to say they staff and dr werent too up on things. Sorry if this sounded rude, it wasnt ment to.
   — brandy H.

April 23, 2004
Okay - I'm confused - why would your insurance cover a panniculectomy and not an abdominoplasty? I do know where you are coming from, though. My plastic surgeon sent in a request for coverage of a panniculectomy - not the abdominoplasty we talked about. My insurance company specifically says that pannis are cosmetic and not covered, and I told her that when I went for my consultation. A panniculectomy just removes the hanging tissue, but an abdominoplasty not only includes removal of the extra tissue, but also includes tightening the abdominal muscles and gives you a smaller waist. (Or in my case - a waist, period, since I don't think I ever had one!). I do work for an insurance company, and I can tell you from experience that we get a lot of members who are ticked off when something isn't covered because "nobody told them". At any rate, surgeons are human and they screw up like everyone else. To be honest, most of them have form letters they have someone in the office adjust to fit your needs, and all they do is sign it. Write your own letter to the insurance company. I went from being denied to having my request reviewed next month. Still not approved, but not denied at this point! (It is going to review because I found a loophole in the policy.) P.S I didn't intend to come off sounding mean in my first response.
   — koogy

April 23, 2004
Hi Brandy..hang in there. Just a general comment first. It's kind of a loaded question to ask "has anybody else been covered" for this or that surgery. The insurance plans are so different, have different exclusions, and different benefits. Plus no 2 patients are exactly alike...so it's hard to get hopeful (or depressed!) when somebody else says "mine was covered...or not!" My advice: get a PS who will hang in there with the INS companies...s/he should have a coordinator or INS person to check status for you periodically. Do all the things that have been mentioned here many times about proving the MEDICAL reason you need the surgery (rashes, skin infections in your case.) Get your primary care doc involved. And get info on all options: financing, different fees at different hospitals, etc. It pays to "shop around" (within the U.S.) in this!
   — DrL