You may be able to get insurance coverage. Your surgeon should have appealed the denial with detailed explanations. Pre-authorization is tricky with non-cancer breast reconstruction, as insurance often treat this as though the patient is trying to get a cosmetic procedure covered by the insurance plan.

A typical submission includes diagnostic codes, as well as specific "CPT codes" for the actual components of the procedure that the surgeon is proposing. Sometimes the patient has to ask for an appeal and press her case through escalation up to the medical director in her region for approval and sometimes it still is not given. Every case is a little different. Your surgeon must advocate strongly for the patient in all documentation and phone calls to the insurance.

Published on Jul 11, 2012

Every insurance has different provisions or benefits often based on your premiums, preexisting conditions, and possibly now in what state you reside. I suggest you read your current policy carefully and any policy you purchase in the future.

Michael Eisemann M.D.
Plastic Surgeon
Houston

Published on Jul 11, 2012

Thank you for your question. Your first step would be to schedule a consultation with a board certified plastic surgeon for a thorough evaluation and consultation. At the time of your consultation, your surgeon will document your medical history and all physical findings (anatomy), and it is this information that can be submitted to your insurance for medical necessity consideration. Any documentation from other physicians (primary care, gynecologist, etc.) can also be helpful in this respect as it will help to strengthen your specific case. The frustrating part about insurance coverage is that it can be a lengthy process that often requires appeals following initial denials and there is no guarantee that your insurance will ultimately approve the medical necessity request. I would recommend remaining in close contact with your plastic surgeon of choice and/or his/her surgical coordinator (as well as your insurance company) during the process. I wish you the best of luck!

Published on Jul 11, 2012

Your surgery should be covered by insurance but everyone is different. Maybe your plastic surgeon should include photographs and letter from your primary care doctor to substantiate.

Published on Jul 11, 2012