Denied by insurance

[Xavier]

My insurance company recently informed me that they deny to pay for my surgery. My surgeon told me he will send them another letter telling them that they should at least invite me for a consult to get checked by the doctor of the insurance company. The only problem is that I waited a long time at first only to hear that the claim will be denied, and this time it will take even longer for them to process the letter of my surgeon. As I already have the money I am thinking of just paying for it as I don't have the time and patience to wait months again only to hear that insurance still won't cover it.

Any advice?

[hammer]

I would have to say that if the surgery is that important to you, then you pay for it and if then insurance pays for it you will get your money back. As you said you have the money, unless I misunderstood what you said.

You must do what is best for yourself as long as no one else suffers for those actions!


Bob

[anoroc]

My understanding is that most of the time they won't pay.  If you can afford it than I think you should just do it.  I finally did it at age 45 and I have to tell you I wish I would have done it ten years ago.

[xelnaga13]

In order to get your insurance to cover your gyne surgery, you need to find out what the conditions for coverage are for that particular surgery. You need to complete all their requirements in order to put them in a position where they HAVE to cover your surgery. Going to your surgeon and asking for a letter is simply not enough. Before my visit to my surgeon I called up blue cross and inquired about what kinds of proof and conditions they needed.

1. letter from primary stating you are in good health and not on medication that causes gyno
2. ultra sound proving actual glandular tissue
3. endo blood work showing hormones are in good ranges
4. letter from surgeon documenting your condition
5. you are in significant pain and have been for a period of time

I got all that together, my surgeon bundled it and sent it away. I was approved a few weeks later.

P.s. a lot of guys think its a good idea to include a letter from their shrink. This is a huge red flag for insurance companies, as they do not care about your mental pain. Only physical pain.

[Xavier]

In order to get your insurance to cover your gyne surgery, you need to find out what the conditions for coverage are for that particular surgery. You need to complete all their requirements in order to put them in a position where they HAVE to cover your surgery. Going to your surgeon and asking for a letter is simply not enough. Before my visit to my surgeon I called up blue cross and inquired about what kinds of proof and conditions they needed.

1. letter from primary stating you are in good health and not on medication that causes gyno
2. ultra sound proving actual glandular tissue
3. endo blood work showing hormones are in good ranges
4. letter from surgeon documenting your condition
5. you are in significant pain and have been for a period of time

I got all that together, my surgeon bundled it and sent it away. I was approved a few weeks later.

P.s. a lot of guys think its a good idea to include a letter from their shrink. This is a huge red flag for insurance companies, as they do not care about your mental pain. Only physical pain.

Well, in the Country I am in, the only way for insurance to cover surgery, is for the surgeon to send a letter to the insurance company. It's quite a standard letter.

Here's the letter from the insurance company (roughly translated):

"We hereby deny to pay for your gynecomastia surgery.

There are a few reasons why:

The government decides what types of plastic surgery's insurance covers. We only pay gynecomastia surgery if:
If there's a clear indicator of breast tissue
If the gynecomastia exists for longer than 12 months
If you have severe pain in the breasts
If the breast looks feminized, comparable to Tanner Stage M4 or larger.
Your BMI should've been below 30 in the last 12 months.

We did not see that any of the points above apply to you in the letter sent to us by your surgeon."

I meet all points beside the BMI and pain thing. I lost like 100 lbs in a year and my BMI was obviously above 30. I told my surgeon that I lost a great amount of weight and he wrote it down. I guess I should not have told him that...

Anyway, here is the letter my surgeon sent to the insurance company after the claim was denied. (again, roughly translated)

"Dear colleague, I received your letter regarding the denial to pay for my patient ......

My patient has lost more than 100 lbs and suffers from severe drooping of the breasts with a great deal of excess skin.
It is so severe that I urge you to see my patient in your office and to rethink the denial."

[cduub]

Dude did you read xelnaga13 post,thats exactly what he said!!!! Its the same reasons they are declining coverage. Listen to the steps that xelnaga13 just told you because it works,it just takes a little more time. Make sure you state PAIN because they dont want any lawsuits for a 4k surgery. CALM DOWN AND LISTEN!!!

[Xavier]

Dude did you read xelnaga13 post,thats exactly what he said!!!! Its the same reasons they are declining coverage. Listen to the steps that xelnaga13 just told you because it works,it just takes a little more time. Make sure you state PAIN because they dont want any lawsuits for a 4k surgery. CALM DOWN AND LISTEN!!!

I received a letter from my insurance company asking me to send pictures of my gyno. Waiting for an approval letter now.

[Xavier]

Will be having surgery in 6 weeks. I paid for it myself as insurance denied to pay for it even after I sent them my pictures. A thread will be made one week pre-op.

[HellandBack]

Good luck bro keep us posted