can anyone help me with some insurance questions? /for my plastic surgery

[suze]

Ok so I mentioned so long ago that I was trying to get a breast reduction approved by my insurance. Well long story short is that I have doctors who have declared it medically necessary and it fits all guidelines issued for United Healthcare... Problem is, My mom's company has a plan that has an exclusion that states NO MATTER WHAT it will only cover this type of surgery if its necessary under the women's breast cancer act. I've tried to appeal but the decision keeps coming back that I don't have enough benefits to cover this type of surgery.

so my questions are:

-Anyone ever deal with this type of situation with insurance companies??
-How does it work if I would change insurance companies now, would the next company state that this is a previous condition and not cover it??
-Then I'm thinking that if I just take out private insurance through United Healthcare and pay my own premium with higher deductibles ect. That maybe they will cover it??

I'm so confused when it comes to this kinda thing. All I know is I need it done and it will cost me 6-8 thousand out of pocket if I don't get it covered by insurance.

any advise I would love... but please don't tell me to just exercise and deal with larger breasts, I've heard it all and the situation is to the point that I need the surgery. Not being mean I just hear it a lot sorry

[Julie Billingsley]

Have you seen the surgeon yet? If not, see if you can find a surgeon in your area that specializes in breast reduction. Their office probably knows all the hoops that need to be jumped through and which insurances allow the surgery. Unfortunately many "elective/cosmetic" surgeries are not covered by many plans... for instance, weight-loss surgery which certainly improves health, isn't covered by many plans. It's a shame that surgeries that help improve health and wellbeing aren't covered. And like, I have a mole that I want removed, but because my doc doesn't *think* it's cancer, it won't be covered by insurance. Seriously. It's considered cosmetic. whatever. Long ago I use to work for an insurance company and for surgeons and I still think their exclusions are crazy. I hope you find a way to get it done! Try calling some surgeon's offices- hope they can help!

[suze]

Originally Posted by Julie Billingsley

Have you seen the surgeon yet? If not, see if you can find a surgeon in your area that specializes in breast reduction. Their office probably knows all the hoops that need to be jumped through and which insurances allow the surgery. Unfortunately many "elective/cosmetic" surgeries are not covered by many plans... for instance, weight-loss surgery which certainly improves health, isn't covered by many plans. It's a shame that surgeries that help improve health and wellbeing aren't covered. And like, I have a mole that I want removed, but because my doc doesn't *think* it's cancer, it won't be covered by insurance. Seriously. It's considered cosmetic. whatever. Long ago I use to work for an insurance company and for surgeons and I still think their exclusions are crazy. I hope you find a way to get it done! Try calling some surgeon's offices- hope they can help!

yeah I want to keep asking around. I'm just so close to just paying the 6 grand and just have it taken care of. Thats the amount of pain its causing me. I just really can't afford that.

[JenTapler]

I second what Julie suggested - ask the surgeon for suggestions. They want to get paid too and they're more likely to get paid if it's covered by your insurance.

If you're thinking of taking out a private insurance plan, do you have to go with United Healthcare? I don't know anything about them, but I work for Kaiser Permanente (a non-profit HMO with excellent ratings) and they cover all kinds of things like this. Here in Hawaii they cover Bariatric Surgery for most people over a certain BMI (body mass index) and I'm involved as the team PT in an ongoing group study for this where we've been able to show that people who undergo bariatric surgery (just to use that as an example) have SIGNIFICANT health benefits that in turn reduce the healthcare cost to the insurance company - so they are seeing that it's actually cheaper for them to pay for the surgery than it is to pay for ongoing treatment for the original condition. The hope is that other insurance companies will use the results of our study to change their own practices and start covering some of these previously considered "elective" procedures. I don't know how common it is with Kaiser nationally, but I've had at least 5 patients in the past year who've had covered breast reduction surgery through Kaiser because of chronic back / neck pain. So there are definitely insurance companies out there who cover it. I would shop around a bit.

[glumirk]

Also, see what your doctor charges for people paying out of pocket and see if there is a payment plan. Because insurance plans never pay what they are charged, doctors have to inflate their prices.

[Julie Billingsley]

oh and definitely keep up the fight for this because you have to look at the total cost... the surgeon might be $6,000-$8,000, but then add in several more thousand for the hospital, the lab work, the anesthesiologist, and anyone else that can take your $$. It adds up!

[color of my heart]

i'd fight it. if it's medically necessary: if it's causing you daily pain and aggravation and stress, causing discomfort and frustration, then it needs to be covered. at least to an extent.

when i did both of my reductions (i had two), i was on a different insurance (blue cross blue shield). and it was covered completely, both times, because of the amount that they took out during surgery. it was a process to get the first one covered, and i had to have lots of letters and documented proof that yes, i was having chiropractic issues. and yes, it was causing mental health problems. and then i had to do the original appointment with the surgeon. which is when he told me that he'd be taking X amount (i can't remember exactly) out. and then he told the insurance. and they were like, "oh, guess it's necessary then".

also, united healthcare isn't that great, in my opinion. i have them currently, and i hate their coverage. but seeing as i refuse to change my residency to NY because i'm only planning on being here for another year or two, i can't get state insurance. and i NEED some type of insurance. but i hate insurance. hate it. insurance companies are ridiculous. and the whole system sucks. /rant.

[nikkiARNGwife]

I didn't have any trouble having mine declared medically necessary b/c they took out a total of 14 1/2 lbs. But be aware also like Julie said that the cost will probably be much more than you anticipate once you get the final bill. I think mine was nearly 12,000 once everyone got paid. (but that was 10 years ago).

Definitely have your surgeon and his staff get on it. The insurance company needs to know how much he plans on taking out..I think when I had mine done there was an actual number of lbs that was allowable before insurance would pay.

[suze]

Originally Posted by JenTapler

I second what Julie suggested - ask the surgeon for suggestions. They want to get paid too and they're more likely to get paid if it's covered by your insurance.

If you're thinking of taking out a private insurance plan, do you have to go with United Healthcare? I don't know anything about them, but I work for Kaiser Permanente (a non-profit HMO with excellent ratings) and they cover all kinds of things like this. Here in Hawaii they cover Bariatric Surgery for most people over a certain BMI (body mass index) and I'm involved as the team PT in an ongoing group study for this where we've been able to show that people who undergo bariatric surgery (just to use that as an example) have SIGNIFICANT health benefits that in turn reduce the healthcare cost to the insurance company - so they are seeing that it's actually cheaper for them to pay for the surgery than it is to pay for ongoing treatment for the original condition. The hope is that other insurance companies will use the results of our study to change their own practices and start covering some of these previously considered "elective" procedures. I don't know how common it is with Kaiser nationally, but I've had at least 5 patients in the past year who've had covered breast reduction surgery through Kaiser because of chronic back / neck pain. So there are definitely insurance companies out there who cover it. I would shop around a bit.

I'll be for sure checking them out. The only reason I was thinking of sticking with United Healthcare because the only reason I think they aren't covering it is because I don't have enough benefits, so my thought process is they will if I take out a private plan with them, with more benefits. I honestly don't know if that will work or not. I'm just thinking if I keep with the same company that knows what I'm going through already it would be easier than start from scratch.

[suze]

Originally Posted by glumirk

Also, see what your doctor charges for people paying out of pocket and see if there is a payment plan. Because insurance plans never pay what they are charged, doctors have to inflate their prices.

yeah this is my charge, and no payment plans are available

[suze]

Originally Posted by color of my heart

i'd fight it. if it's medically necessary: if it's causing you daily pain and aggravation and stress, causing discomfort and frustration, then it needs to be covered. at least to an extent.

when i did both of my reductions (i had two), i was on a different insurance (blue cross blue shield). and it was covered completely, both times, because of the amount that they took out during surgery. it was a process to get the first one covered, and i had to have lots of letters and documented proof that yes, i was having chiropractic issues. and yes, it was causing mental health problems. and then i had to do the original appointment with the surgeon. which is when he told me that he'd be taking X amount (i can't remember exactly) out. and then he told the insurance. and they were like, "oh, guess it's necessary then".

also, united healthcare isn't that great, in my opinion. i have them currently, and i hate their coverage. but seeing as i refuse to change my residency to NY because i'm only planning on being here for another year or two, i can't get state insurance. and i NEED some type of insurance. but i hate insurance. hate it. insurance companies are ridiculous. and the whole system sucks. /rant.

I'll keep blue cross blue shield in mind too.

[color of my heart]

Originally Posted by suze

I'll keep blue cross blue shield in mind too.

it's not cheap by any means. but it's awesome insurance.

[lovely1m]

Originally Posted by Julie Billingsley

And like, I have a mole that I want removed, but because my doc doesn't *think* it's cancer, it won't be covered by insurance. Seriously. It's considered cosmetic. whatever.

Julie, tell them its rubbing on clothing or something and really bothering you. I had one removed off my neck, the main reason was I just didn't like it there, but my doctor was like, "This rubs on your webgear (something I wear at work), right?" lol He said insurace would cover it that way.

[suze]

Originally Posted by color of my heart

it's not cheap by any means. but it's awesome insurance.

yeah they want 500 dollars for the three of us. They are the only company that will even consider anyone for pre-existing conditions.

I talked to a bunch today... looks like I wont be covered by anyone, 50/50 shot on blue cross, and uh wont give me my own insurance and give me my surgery. I'm so out of options.

[Sarah8914]

I hope you can figure something out!

So, I'm totally baffled by this mole thing. My hubby totally had a mole removed in just a regular visit!

[lovely1m]

Originally Posted by Sarah8914

So, I'm totally baffled by this mole thing. My hubby totally had a mole removed in just a regular visit!

Yep, its an easy procedure, but some insurances consider it cosmetic and won't cover it unless the doctor thinks it could be cancerous.

[color of my heart]

Originally Posted by suze

yeah they want 500 dollars for the three of us. They are the only company that will even consider anyone for pre-existing conditions.

I talked to a bunch today... looks like I wont be covered by anyone, 50/50 shot on blue cross, and uh wont give me my own insurance and give me my surgery. I'm so out of options.

i really hope you figure something out. /: