Surgeons Office Refused To Submit To Insurance Co. For Pre-approval

[Caslas213]

I'm a 38 year old disabled for the last 5 years after a failed back surgery destroyed my life. I had the best job in the world as a Police Sergeant here in Missouri.

I went and discussed my gynecomastia  with my family doctor. He sent me to see a plastic surgeon. Due to my back and my 7 back surgeries (since my failed surgery) the plastic surgeon told me it is definitely medically necessary since my back and the pain I have in my chest.

My boobs hurt so bad everyday, I can't even have a shirt touch my nipples. I'm stuck inside of my home. He took photo's and told me he would sent a letter and pics to Medicare, but he see's no reason at all why it will be a problem getting it approved.

The plastic surgeons office called today and I was informed that they will not even submit my case to Medicare because they won't approve this. I told them what the doctor had told me and she got hatefull with me and said again it will not be sent to Medicare. I tried to talk to her and she became angry and rude so I hung up the phone.

I called back an hour later to make an appointment to see the doctor and she refused to let me make an appointment. I called my family doctor and now can't be seen for almost three weeks.

Please someone help me! I feel like just giving up on life. What do I do? I felt very good about what the surgeon told me at the appointment, but now I'm so upset, hurt, disappointed, feel helpless, and I don't know where to turn. I have money set aside for this surgery in case it's not covered.

Now I just want it done ASAP even if I have to travel.
 It's ruining my life.


Thank You......Stan

[Dr. Elliot Jacobs]

It has been my impression that Medicare will not cover anything that even smacks of being cosmetic.  However, I do believe a surgeon should cooperate with you in submitting a letter of pre-approval.  I would agree with his office, though -- you should expect to wait a long time for an answer and the answer would most likely be a rejection.

I have opted out of Medicare, so I am not even allowed to treat a Medicare patient.

If your breast pain is recent in origin, you should have it worked up first by an endocrinologist before any surgery is contemplated.

Dr Jacobs

[Caslas213]

Thank You. I do have an appt. to see an  Endocrinologist next week.

[DrPensler]

I also do not participate in medicare. I have found for the last 12 years or so insurance will not cover the procedure. Insurance companies and medicare used to cover the procedure but no longer do so.

[Litlriki]

I do participate in Medicare, but there are certain insurance situations, including Medicare, where we are unable to obtain prior authorization.  Medicare prior authorization is normal obtained through the secondary insurance, which is often Medicaid, and in such cases, it is impossible for us to get any information, and even if we get prior authorization, we never get paid.  As a result, it is a complete waste of our time to attempt submission.

While I think that health insurance should be universal and coverage should be consistent, this isn't the case, and the idiosyncrasies  of our system create situations like this that most patients find difficult to understand.  I had two patients approved by their insurance last year.  I have still not received payment for the first, and I was paid $760 for the second.  That procedure cost me more than I made, to be sure, and we have determined that we will only accept the insurance payment if they'll pre-negotiate with us, so that we know what we are going to be paid.  Because the insurers pay me based on where I work, and the hospital where I work has not negotiated payments on my behalf (or if they have, they've done a poor job of it), I have no choice if I want to be able to pay my bills.

Rick Silverman