Anyone had a patient appeal insurance for coverage?

[wvalum07]

My situation:
I've had gynecomastia since I was 10, now 30 years old. My insurance Highmark BC/BS offers coverage for mastectomy for gynecomastia if I meet the requirements laid out American Society of Plastic Surgeons.

I met with a surgeon a month ago, and he classified my gyno as a III, which meets requirements. Also my BMI falls within the guidelines. He submitted all my information and we are now just waiting for word.

However, before leaving the consultation, the office staffer that handles the insurance side warned me that there was a good odds they would deny the claim. This is apparently common place and it would require writing an appeal.

Of course, I am hoping it is approved on the first try, but if not I want to be ready with a letter pre-written.

I wanted to see if any of the doctors here have had a patient successfully write an appeal, and what did they include?

[Litlriki]

I have had three patients successfully get insurance coverage in the past two years.  They coordinated their own appeals and did this on their own. All three had Blue Cross Blue Shield.  The first patient had pain and in his appeal letter, he questioned why they paid to have other painful lumps removed, but wouldn't pay to have his painful mass removed. The second patient was a police officer, and I've had a police officer get approved before related to his bullet-proof vest, but I'm not sure why this one was approved. The third patient was a physician.

I was never paid for the first procedure, and the patient is currently in Africa. I was paid $760 for the second procedure by the insurance company, which doesn't effectively cover my costs to do the procedure.  So when the third approval came through, I contacted the insurance company to see if I could negotiate a reasonable payment for the procedure, and after speaking to several very nice people, I was advised that i would be paid $760.  Again.  We aren't allowed to "balance bill" in Massachusetts, so that's all I'd get.  I will now submit if patients want to try to get coverage (to pay the hospital and anesthesia fees), but I no longer accept insurance for my fee.

To answer your question, if your doctor does a lot of gynecomastia surgery, I would suspect that he or she has had similar experience to mine and will have little enthusiasm for writing appeal letters. Moreover, the appeal letters are generally more effective when they aren't from the surgeon who is to theoretically benefit should the procedure be approved.   Just the reality of practicing medicine today.

Rick Silverman

[Dr. Elliot Jacobs]

A hearty thank you to Dr. Silverman for explaining the insurance situation.

The sad fact is that insurance very rarely covers gyne surgery, despite the fact that it is a recognized medical condition.  They call it cosmetic and then dismiss any claims.

Virtually every gyne operation requires the use of liposuction in order to achieve a smooth contour after removal of gland tissue.  And every surgeon will note this use in his operative report, which must be included in any submitted claim.  Even though a lipo instrument is being used  just as a scissor or a scalpel is being used, once the word "lipo" is mentioned in the report, it automatically becomes "cosmetic" and hence denied.

Finally, I could not remain in practice if I accepted what insurance companies pay for the surgery (if they pay at all).  As Dr. Silverman said, the reimbursement does not even cover the costs of doing the operation.  It is an insult to a surgeon who has put in many years of study and work in order to provide the best of medical care to a patient.

I don't think a plumber would come to your home to evaluate a problem if you promised to pay him $20 for the visit.

Dr Jacobs

[DrPensler]

For years  ( over 10 ) I have had minimal ( virtually no )success with insurance companies. I even spoke to the head of Blue Cross Illinois about a patient to no avail. There is a substantial difference in what you may perceive an insurance company said to you over the phone and what they have legally said and what happens. If you look closely at anything that is sent to you prior to surgery there are invariably several qualifiers throw in which unsophisticated consumers do not recognize.