Can you appeal health insurance claim denial?

Question

I am trying to have a breat reduction and the my health insurance company had denied it. What can I do?

Answer 1

Christy, breast reduction is considered a cosmetic surgery and such a claim is not allowed as the terms and conditions have specified clearly. However, if the doctor's report can clearly prove that it is needed on medical reasons; then your claim should be approved.  Do check with your insurance agent for more details.

Answer 2

If your doctor did not recieve a copy of the denial letter, take it to his office. Chances are he has dealt with this in the past and will know what documentation is required to send to the insurance company to have it reconsidered. As was previously posted, they may just deny it the first time to see if that gets you off their back. Keep trying. If necessary, get a second opinion.

Answer 3

Yes you can definately appeal. they are probably claiming it is cosmetic, and you will have to prove it is for medical reasons...thats why your Dr. planned on appealing it. It is probably an automatic denial from the insurance co, hoping you will drop the issue. I have a constant neck problem and after injuring my neck( unrelated to the problem) they tried to deny me on a preexisting condition. My Dr. had to appeal. They are trying to save money...what they want is proof you NEED the surgery.

Answer 4

Insurance companies have guidelines to determine covered expenses.  Is this cosmetic?  Are you large enough that at least a certain percentage of fat would be removed?  Do you have back problems because of the weight of your b*****s?  Your Dr. would document all the problems to show if this is medically necessary and not just an elective surgery.

If your Dr. feels this would improve your lifestyle, he would write the necessary letter to obtain pre-certification for you.

Answer 5

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Answer 6

Fight it.  Appeal and fight it some more.  The more fuss you make the more chance of them changing their mind.  Remember they make a lot of money by blowing people like you off.  Most people just give up, and that saves them a fortune.

Answer 7

Yes - all insurers have appeal or greivance procedures.  Your key will getting the doctors to justify it on medical rather than cosmetic grounds.

Answer 8

Most likely this claim will be denied in the end.

I do have an idea though.

Ask if you can switch coverage to a high deductible HSA, (health savings account,) qualified plan if offered to the employees. Use the money deposited in the account to pay for the operation.

If the insuror sticks to their decision to deny the claim, ask the provider if he/she will accept the allowed amount had it been accepted.