Insurance coverage / predetermination on gynecomastia surgery

[Joe415]

Hi Everyone:

I would like to ask everyones opinion.  I did a predetermination for my gynecomastia because I have a morphine pump for chronic pain, and I am on hormone replacement from it.  My endocrinologist noticed my gynecomastia and suggested that I see a surgeon and told me she could have it covered through insurance by writing a detailed letter which she did.  I had 2 other doctors as well who wrote letters stating that it was medically necessary.  I even had a weight watcher report of over 30 pound weight loss.

The 3rd party insurance company recommended that it was medically necessary, but the insurance company still denied the claim and said they have the final say.

I am doing an appeal, but I wanted to ask you all if anyone else encountererd such a
situation.  I do not feel it is at all fair and I am very disbured by this.

I had the surgery Monday and paid out of pocket, I am not even sure I could be reinbursed if I win the appeal since I did not wait for the decision.  I would have had to wait until April!

Any suggestions on what else I can do?

[liton2k]

just pay for it , it is worth all the money ... if you dont have problem waiting then you should wait i think..

[Joe415]

I did pay out of pocket on Monday.  It is life changing. I am so happy... However I am still going to fight for my apeal, and resubmit it.

[Dr. Elliot Jacobs]

Prime example of the ploys used by insurance companies -- there is absolutely never a guarantee of payment until a very rare check arrives. And when you appeal, who to you appeal to?  The same company that denied you in the first place.  Great system! That is why virtually all plastic surgeons require pre-payment for this surgery.

Dr Jacobs