How do I Appeal an Insurance Company That Declined a Breast Reduction?
In some cases, insurance companies deny a breast reduction when doctors try to get an authorization for coverage. Patients do have the right to appeal this decision, meaning that all is not yet lost. The main reason for denial is that the insurance company considers the breast reduction to be cosmetic surgery, and therefore not medically necessary. However, women with large breasts often suffer from a variety of painful conditions that could be lessened through reduction surgery.
Instructions
1. Familiarize yourself with your insurance company's policies. If the procedure is not covered at all, you may be able to ask for a rider or that they make an exception. If it is covered, check into the criteria for approving the procedure. This could include minimum cup sizes, weight or volume; body mass index or percentage on the Schnur scale; or any deformities of the breasts or shoulders.
2. Get a second opinion or see doctors about any related conditions you suffer from. For example, you could see a chiropractor if you have back problems, or a psychologist if you're experiencing body image problems. Go a gym to try to lose weight, which may make your breasts smaller. Keep documentation of all methods and treatments you've tried prior to surgery, so that you can back up your claims to the insurance company.
3. Draw up a letter explaining why you are requesting the surgery, detailing the pain and discomfort you feel and any related conditions you are suffering from. Cite facts to back up what you're saying. Using an emotional appeal can help your case, but insurance companies won't approve anything based on emotion alone.
4. Request that your primary care physician or plastic surgeon also write a letter to the insurance company. This will hold more water than your letter alone. This letter should only state facts and outline why the doctor believes the breast reduction is in your best medical interests. You can also request letters from any other doctors you've seen for related conditions.
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