I need someone who got the SURGERY COVERED by INSURANCE! Bluecross Blueshield!

[Kill3rK]

Hey everyone! I'm hoping you can help me. Ive been browsing this site + others for some time now, but just recently seriously started considering surgery. I have an appointment set with a plastic surgeon for Thursday, but I have some questions first. My DR. is John Bruno from Ft. Myers, Florida. Does anyone have any experience/ or have the resources to check this doctor out? I have looked at some of his work and it looks pretty good. What will this consultation mainly be about? This is the first time I will have spoken to him. I'm an 18 year old college student, and I am flat broke, so I'm praying that my insurance (Bluecross Blueshield) will cover the surgery. I know I need to tell him I'm in a lot of pain, and I cant sleep at night, but what else? What will really drive home the point that this isn't just cosmetic but medically necessary? Should I mention Breast Cancer in men runs in my family? Which it doesn't, but my grandmother, and great grandmother had it. Please don't comment and say "Well it really is only cosmetic so the chances are slim to none" i know what the chances are, Ive read almost every post like this one, but Ive also read a lot of posts about people successfully getting it covered. One guy said he stuck a needle onto his nipple and made it bleed, and let the blood dry there and showed it to the doc. LOL that's too far for me. Also, I know its not recommended that you drive after the surgery, but what if I hang out in the hospital for a bit? Because ill be having this surgery done on my own, no one will know.

[snugglebandit]

Not to be a downer, but BCBS will not be covering your surgery man. I fought that for oh....about five years and those bastards never sent me a dime. Start saving your money or take out a loan.

[xelnaga13]

I just had my surgery covered by BC BS.

[Kill3rK]

Xelnaga, how? I went to my PS had the consultation, he submitted it, and it was denied. I didn't go to an endo or anybody, just a ps.

[xelnaga13]

You need the following:


1. Note from primary stating you are in general good health and not on any medication that would cause gyno
2. Blood work showing your hormones are stable
3. Ultrasound showing actual breast tissue ( not just fat)
4. Letter from PS stating your condition, your pain, his recommendations
5. PS send in photos of your condition

All of the above is bundled by the PS and sent as one.

You can get all of these tests and apts. in one week if you tell them you need it before a surgery that is pending shortly.

[xelnaga13]

Also- I would never suggest being less than honest with your doctor. All though I doubt you would be prosecuted, lying to insurance companies can get you in trouble.

[prabil]

Xeinega:  did insurance pay for your bloodwork and ultrasound.  I am about 2 months post lipo only.  Lipo did not do a thing and the glands hurt inside my moobs.  I can't run or even walk fast.  When I bounce it hurts.  I'm thinking of getting bloodwork done to make sure hormones are ok. And getting a mammogram or ultrasound.  At this point I shouldn't have that much fat left, it should be mostly gland and submitting it to the insurance company. I need a redo.

[xelnaga13]

@prabil- Insurance covered all the tests.

[Kill3rK]

My PS submitted my pictures and his notes and thats it. I've been in contact with his staff as well as BCBS and they told me that brcause this is an outpatient surgery, I don't need pre-authorization and because my PS is apart of the recommended surgeons program for BCBS, I was all set. BCBS also told me that they didn't see anything that my surgeon submitted and they didn't see anything that they denied, so I just asked him some questions about the surgery and getting it covered. It was weird, I've been in constant contact with my PS staff and they told me they submitted it and it was denied, and when I called BCBS they said they never received anything.

[xelnaga13]

@Kill3rK- The beginning of my story is very similar to your experience. My PS told me to wait 3 months for an answer... I waited patiently, then on the 90th day of waiting I called my PS staff. Only to find out they never sent in the package. I literally came within 15 days of being off my parents high end commercial insurance and losing any chance for getting this surgery. From that point on I micro managed every aspect of my surgery.

Also... When you need your insurance company to send something in writing stating that they will cover the surgery. I have heard stories about insurance companies refusing to pay after the fact. Unless you have a written approval for coverage you have nothing.

Based what you have said I think its time to find another PS. Although my PS staff messed up sending the material in; they were well versed on all the tests needed to get the surgery covered.

[art]

You need the following:


1. Note from primary stating you are in general good health and not on any medication that would cause gyno
2. Blood work showing your hormones are stable
3. Ultrasound showing actual breast tissue ( not just fat)
4. Letter from PS stating your condition, your pain, his recommendations
5. PS send in photos of your condition

All of the above is bundled by the PS and sent as one.

You can get all of these tests and apts. in one week if you tell them you need it before a surgery that is pending shortly.

Did you get this info directly from BC BS?  I guess I'm asking how you got the info, and how you got the ball rolling on this.  I've been to both my primary and PS, and both have said its next to impossible to get BCBS to pay, which is why I haven't contacted them about it yet.  I have saved the cash to get the surgery done, but if I can get insurance to cover, that would be great. 

[chringram]

I had found this thread while working on my son's procedure and it was helpful so I bookmarked it and now that we DID GET INSURANCE TO PAY FOR IT, I can fulfill my vow to return and post the solution. In case this post does not work as the topic is old, I'll start a new thread as well. But here goes in case you find it here.
Since my son was a teenager with diagnosed Gynecomastia it was troublesome to locate a surgeon who would help. In fact there was one in Beverly Hills who believed my son should lose significant weight and he would not touch this case. Prick!
None-the-less, and in the words of a great singer, "we never weary!"
We scheduled the surgery, took out a credit card to pay for it, had the procedure done, then filed for reimbursement from the Blue Shield PPO. Although the claim was denied, what follows is my APPEAL letter. This approach worked!! My letter coupled with the fact that Blue Shield messed up the claim and sat on the response too long rendering them no other choice but to reimburse me helped seal the deal. There are links provided as well in case you need to reference things.
TIPS TO KEEP IN MIND
1. Call insurance company's customer support frequently and document all calls and communication. This includes: who you speak with, who their manager is, what was discussed, ask for a reference ID # for the conversation. Keeping a running log of all communication (phone, mail, fax, etc) limits their options for further denial
2. The practice of removing large amounts of tissue is working to eliminate the opportunity for CANCER. Drop that in your responses when you can.
3. Demand (in writing) the insurance company put things in easy-to-understand language with detailed explanations on any decision they make. Their 'auto-generated' forms that insurance companies mail you NEVER have this information, but by law they have to provide. Example is: I HAD RECEIVED INFORMATION THIS CLAIM REFERENCED ABOVE WAS NOT SUBJECT TO DEDUCTIBLE AND REQUESTED A COPY OF THE JUDGMENT AND RELATED FINDINGS. I HAVE NOT RECEIVED THIS INFORMATION. UPON RECEIPT OF THIS FAX, PLEASE SEND ME A COPY OF THE SCIENTIFIC OR CLINICAL JUDGMENT USED FOR THE DETERMINATION OF THIS CLAIM. .... When they don't respond to this request and 30 days go by, they did not follow the letter of the law and are no longer in compliance.
5. Since we had Blue Shield, this link below was a great resource that defined their ACCEPTANCE criteria for covering the procedure: www.empireblue.com/medicalpolicies/policies/mp_pw_a053474.htm
6. There are more links below, here are some not included in the APPEAL letter that helped me!
http://www.npr.org/sections/health-shots/2014/04/14/302547851/patients-often-win-if-they-appeal-a-denied-health-claim
================
APPEAL RESPONSE. (So now to the meat of it all! My son's surgery was denied on the basis of 4 different areas. My appeal dealt with each of them. Enjoy and .... God willing... I hope it helps you all!!)
================
DATE: xx/xx/xxxx
Patient Name: NAME <DATE OF BIRTH>
Relation to Subscriber: <DEFINE RELATIONSHIP>
Diagnosis: 757.6 Specified congenital anomalies of breast
Provider Name and Address: < ADDRESS, TELEPHONE, FAX >
Insured: <YOUR NAME>
Subscriber Number: <YOUR NUMBER>
Group Number: <YOUR GROUP>
Dates of Service: <DATE>
Procedure Codes: CPT Code 19300 Mastectomy for gynecomastia
Claim number: <CLAIM>
Dear Claims Review Department,
I have decided to appeal your decision to deny coverage of my son’s recommended treatment plan of mastectomy for gynecomastia. Since my son’s diagnosis, the serious medical condition has adversely impacted his life and daily activities. He had already tried various other treatments for the condition which are outlined below. These are the basis for the rationale used to determine that <PATIENT NAME> have the mastectomy. There was significant relief which followed the surgery. Mastectomy to treat gynecomastia has been proven to have an extremely low complication or re-admission rate and regularly covered by private payers such as Bupa and Aetna. For your information, I have attached related lab and test results and have referenced medical studies, and articles from scientific journals regarding this procedure. Please take the following into consideration while reviewing this appeal.
Thanks,
YOUR NAME
YOUR CONTACT INFO

BACKGROUND: The patient had undergone careful physical evaluations and testing to identify possible etiologies. Longstanding gynecomastia was diagnosed and coupled with the resulting traumatic interference of the patient's activities of daily living, further suspicion of malignancy of breast warranted surgical treatment. Given the severity of gynecomastia could not be remedied through other medical therapies this rendered the only effective solution as surgical removal of tissue.
SUMMARY: Per Blue Cross Blue Shield (BCBG) medical plan language Mastectomy for Gynecomastia is covered when deemed medically necessary. The claim was denied based on the basis of four (4) points. The following responses provide clear insight into the patient’s medical condition, each of which justify the medical necessity of the surgical procedure.
CAUSE OF DENIAL: Patient is greater than 18 years of age or 18 months past puberty
APPEAL RESPONSE: Patient lab results indicate a lack of a growth hormone, an underlying cause of gynecomastia which contributes to delayed puberty. In such cases, mastectomy is indicated regardless of age to properly address concerns. Denying a claim due to an age dependency in a patient who has a documented lack of growth hormone would highlight that the denial was based on a previous medical condition and against federal law. Further, the mastectomy procedure for gynecomastia is considered medically necessary, regardless of age, when there is legitimate concern that a breast mass may represent breast carcinoma.
CAUSE OF DENIAL: Documentation does not indicate that gynecomastia is associated to any condition other than patient’s weight
APPEAL RESPONSE: This is a poorly defined association which confuses the medical diagnosis of gynecomastia with pseudo-gynecomastia. Patient’s records clearly show lack of excess fat deposition in material biopsied as a result of the surgical procedure. In the patient’s case, longstanding gynecomastia and the suspicion of malignancy of breast further warranted the surgical therapy. Additionally, the following was confirmed by the examining physicians and provided with the claim’s original documentation:

• Patient has pain or tenderness directly related to the breast tissue (documented in the medical record) which has a clinically significant impact upon activities of daily living and has been refractory to a trial of analgesics or anti-inflammatory agents
• Pre-operative photographs were provided displaying the severity of gynecomastia

CAUSE OF DENIAL: Documentation does not indicate glandular breast tissue has been confirmed on physical exam and/or mammography or tissue biopsy
APPEAL RESPONSE: Patient’s severity of increased and hardened breast tissue was confirmed by examination and presented in the claim paperwork. Gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. Thus the tissue was removed surgically to eliminate any further risk of carcinomas.
CAUSE OF DENIAL: Documentation does not indicate underlying etiologies or contributory conditions have not been considered or excluded and/or treated
APPEAL RESPONSE: Treatment of the identified underlying conditions was attempted prior to the discussion of surgery. Appropriate diagnostic evaluation had been done for possible underlying etiologies including ultrasound of the thyroid, abdomen, & gall bladder; bone age study; bioimpedence analysis; and blood work. These tests identified an imbalance in IGF-1 and ACTH levels. Medical findings indicate the GH/IGF-I axis is involved in the pathogenesis of gynecomastia. These values recognized in the patient blood work highlight deficiencies that isolate the associated etiology of the diagnosed gynecomastia as well as document the patient’s risk of cancer if left untreated. Attempts to treat failed leaving the surgical procedure as the only option to lessen future risk to the disease state of the patient.
PROCESSING DELAYS: Our initial claim for this procedure was mailed on <INSERT DATE OF ORIGINAL CLAIM>. I did not receive an update of the denial until several months and numerous support line phone calls later. Additionally, I still have not received a response to my request for the scientific judgment and related findings used to determine the denial. These experiences are outside of the boundaries allotted by the ERISA act of 1974. You must respond within a timelier manner as my medical policy dictates. Any further delays to this appeal process will force me to file a federal grievance complaint.
REFERENCES:
Gynecomastia associated with isolated ACTH deficiency.; J Endocrinol Invest. 1987 Apr;10(2):127-9. Shimatsu A, Suzuki Y, Tanaka S.  http://www.ncbi.nlm.nih.gov/pubmed/3035001
Elevated serum IGF-I, but unaltered sex steroid levels, in healthy boys with pubertal gynaecomastia; Mieritz MG, Sorensen K, Aksglaede L et al. Clin Endocrinol (Oxf). 2014 May;80(5):691-8; http://www.ncbi.nlm.nih.gov/pubmed/24033660
Gynecomastia: Etiology, Diagnosis, and Treatment; Ronald S. Swerdloff, M.D. Professor of Medicine, Chief, Division of Endocrinology, Assoc. Chair, Dept of Medicine,Harbor-UCLA Medical Center,1000 West Carson St, Box 446, Torrance, CA 90509-2910; http://www.ncbi.nlm.nih.gov/books/NBK279105/
Breast malignant, males, children Male tumors Gynecomastia in males; Reviewer: Monika Roychowdhury, M.D.; http://www.pathologyoutlines.com/topic/breastmalignantgynecomastia.html
ASPS Recommended Insurance Coverage Criteria for Third-Party Payers; American Society of Plastic Surgeons; http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf
Gynecomastia: Etiology, Diagnosis, and Treatment. Authors Swerdloff RS, NG J. Editors In: De Groot LJ, Beck-Peccoz P, Chrousos G, Dungan K, Grossman A, Hershman JM, Koch C, McLachlan R, New M, Rebar R, Singer F, Vinik A, Weickert MO, editors.  Source Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.2015 Aug 3. http://www.ncbi.nlm.nih.gov/pubmed/25905330

[chringram]

-

[Paa_Paw]

I often chastise people for bringing an old thread back to life but this time I will not.  In fact I'll add to it something that happened so long a go that it has fallen off the archives.  What happened was that a mother had challenged the refusal of their family health insurance to cover her son's breast reduction surgery and she did it in a rather unusual way.   The insurance company suggested that the best way to treat Gynecomastia was with counseling.  The mother of the lad involved countered with a statement from the Psychologist that counseling had no effect on Gynecomastia and the only effective treatment for the lads depression and low self esteem would be surgery to reduce the size of his breasts. 
The insurance company countered with an offer to cover the cost of the procedure, but with a general surgeon, not a cosmetic surgeon. The mother of the lad then questioned if the insurance company was willing to cover countless revisions and the continuing psychological counseling given the high risk of an unsatisfactory outcome under the conditions they were mandating.   Ultimately, the insurance did cover the surgery and with a qualified Cosmetic surgeon. 
Never underestimate the power of a Mother defending her child. 
Some insurance companies specifically have an exclusion for this kind of surgery, but lacking that sort of specific exclusion, an appeal is always worth a try.