Breast Reduction / Insurance Question

[Felicity]

Hello!
It's been a while since I posted here but I do still visit and lurk.

I am really wanting to get my breasts reduced & lifted and I am having problems making my insurance company feel the same way. Unfortunately, since my weight loss, I no longer outright meet the requirements for the amount of breast tissue that needs to be removed in order for Anthem to consider it medically necessary. My denial letter references the codes here: LINK I do have documented cervical and thoracic pain syndrome for which I have been treated for several years AND I still have issues with submammary intertrigo which was diagnosed in 2015.

After my weight loss, my breasts basically deflated almost completely, causing the intertrigo to worsen due to the skin-on-skin contact actually increasing. Sadly, due to my height & weight, my insurance would require that I basically have the entirety of my breasts removed to meet the breast tissue removal weight requirement although I wear a 38 DDD bra (comprised mainly of picking up my breast skin and plopping it into my bra). I have always had grade 3 ptosis - a side effect of going through puberty obese.
I am currently 5'6" and weigh 190. My surgeon recommended that removing 300 grams would give me great results - not only with the intertrigo and lower back pain but also appearance. My insurance's magic number according to his chart is 527 grams.

Has anyone successfully worked with insurance to get their breast reduction approved in a case where you aren't meeting the breast weight requirement?

On a side note, I am pleased by my extended abdominoplasty results from 2016, although I wish I would have waited a little while longer before doing it. I had a brachioplasty last year in September and have some glorious scars from it - and currently, I am loving my first summer EVER being able to wear short sleeves.

 

[DianaCox]

Funny - I just this evening filed my request for external review for the denial of my buttocks lift with fat grafting, and thigh lift. (I don't know if I'll go through with the procedures even if I'm approved, but I wanted to fight the denials anyway, because that's what I do for fun!) Let me explain what the basis for my appeal is, so you can review YOUR documents, including their policy and your Evidence of Coverage (insurance contract) and see what your language says.

I got CareFirst BCBS to approve an insurance-covered abdominoplasty with panniculectomy, by combining it with a hernia repair. But the denial for the butt and thighs was because they claimed I didn't sufficiently prove medical necessity or functional impairment.

The thing is, those two reasons not the ONLY bases under which reconstructive surgery is mandated to be covered, but they are the only ones that were addressed. The basis for denial is that the requested procedures were not being medically necessary or for the treatment of functional abnormalities:

In arriving at this conclusion we considered the guidelines/criteria set forth in CareFirst Medical Policy 7.01.017 Cosmetic and Reconstructive Surgery with Attached Companion Table, which reads:

Cosmetic surgical procedures are considered not medically necessary.
Reconstructive surgical procedures are considered medically necessary.

Buttocks/thigh lifts (15832, 15835)

Cosmetic- To improve appearance by reducing the size of the buttocks/thighs in the absence of medically necessary indications and/or conditions
Reconstructive- When medically necessary due to chronic ulceration, excoriation, or infection.​

However, that CareFirst Medical Policy 7.01.017 contains some very interesting additional statements that the denial CONVEEEENIENTLY failed to mention:

Cosmetic surgeries are those operative procedures performed with the primary intent to improve appearance, not to restore bodily function or to correct deformity resulting from disease, trauma, or previous therapeutic intervention *.

Reconstructive surgeries are those operative procedures performed on structures of the body to improve/restore bodily function or to correct deformity resulting from disease, trauma, or previous therapeutic intervention *.
*****
* Therapeutic intervention, for the purposes of this policy, is defined as any medically necessary surgical treatment.
​

The primary intent of the procedures requested, and twice denied by CareFirst without addressing this clearly stated intent, is (in additional to medical necessity and functional impairment) to correct the deformities resulting from my disease of morbid obesity, and the previous medically necessary therapeutic intervention of bariatric surgery which caused the weight loss.

And what do you know - I had written that part about correcting deformity in the original request for preauthorization, and it was addressed (or perhaps I should say ADMITTED?) by the reviewer in the first denial:

“ased on the clinical information and photographs received, the member has lost a significant amount of weight loss [sic] due to bariatric surgery and now has bilateral redundant thigh tissue and buttock deformity.”​

Yup, they already admitted I have thigh and buttock deformity - and then failed to address the fact that that is a qualifying description for coverage of reconstructive surgery.

So, go find the insurance company's reconstructive surgery policy and your own EoC, and compare what the actual policy is to what the basis for the denial is - there may be an inconsistency you can exploit.

And then appeal, appeal, and get to external review.

 

[Munchkin]

Do what she said!!!!

 

[Spiky Bugger]

Kind of. We fought Aetna. They backed down right away.

It was for our daughter, about 27 years old, not obese, wearing a 36-J bra.

This was some time ago...like over 15 years ago. I went to their website, copied/pasted THEIR criteria, replacing their numbers with our daughter's numbers, which exceeded their requirements.

ALSO, mentioned in our letter that she had been to FIVE, board-certified in-network Aetna plastic surgeons who agreed on the amount of tissue to be removed...and yet their in-house guy denied the claim, and wanted damn near a mastectomy, and, guess what (I went to the state med board site and cheked him out), he was an otolaryngologist.

So...if they felt that their otolaryngologist was a better judge of how much of what was MEDICALLY needed (scoliosis, intertrigo, and a letter from her PCP stating that the tissue was so dense that breast cancer...which was prevalent in her family...would be undetectable) than their five in-network, board-certified plastic surgeons and her PCP, we just might as well go ahead and have the state decide whether it should be covered...tell me please how to proceed...blah, blah, blah...

They called the day they receved the letter and said the denial was a mistake.

But, it was a long time ago...and in the People's Republic of CA where we get back-up from the state.

 

[JackieOnLine]

I wanted to fight the denials anyway, because that's what I do for fun!

Spiky B, I love your stories