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Archive for June, 2013

THE PAPER TRAIL – INSURANCE AND MEDICAL NECESSITY

Friday, June 28th, 2013

In Illinois Plastic Surgeon, G. D. Castillo, MD’s  practice, we do help patients whose cases qualify as medically necessary procedures; i.e., upper blepharoplasty https://www.cosmeticplasticsurgery.com/cosmetic-surgery/eyelid-surgery.cfm for vision constriction (excess skin obscuring vision),  or septoplasty https://www.cosmeticplasticsurgery.com/cosmetic-surgery/rhinoplasty.cfm  to correct a nasal obstruction that interferes with proper breathing and causes recurring sinus-type ailments  or breast reduction https://www.cosmeticplasticsurgery.com/cosmetic-surgery/breast-reduction.cfm to correct gigantomastia (overly-large breasts) resulting in postural changes causing neck and back pain, mastodynia (breast pain), dermatitis (skin irritation) and difficulty with movement.

When submitting a predetermination of medical benefits for these patients, insurance companies do ask for proof of medical necessity.  What does this mean for our patients?

What insurance companies are looking for is proof (a written medical record and/or diagnostic tests) that the patient will not obtain relief from their symptoms via conventional (non surgical) treatment such as medications, physical therapy and/or life-style changes.  Let’s take two hypothetical cases and examine the process and possible outcomes.

Patients Jane and Jenny Doe present for consultation with complaints of large breasts that are causing increasing discomfort .

Examination by Dr. Castillo discloses gigantomastia resulting in postural changes causing shoulder strapping (deep bra strap grooves from the weight of the breasts), neck pain, and back pain https://www.cosmeticplasticsurgery.com/patient-stories/.  They have difficulty with everyday movement and exercise.  They have painful, aching breasts (mastodynia) and suffer chronic dermatitis from breasts chafing against the chest wall.  Their body mass index (BMI) is within the normal range and both will require the insurance standard of 400+ grams of tissue to be removed from each breast.

Jane has suffered in silence for years.  She has not sought professional medical attention for her symptoms in the past and has treated her conditions (dermatitis, neck/back pain, etc.) with over-the-counter remedies – none of which have offered her the long-term relief she desires because they do not address the underlying source of her discomfort – gigantomastia.

Jenny, on the other hand, has been proactive in seeking professional assistance with the goal of long-term relief.  She has sought advice from her primary physician and has undergone treatment with both physical therapy (exercise to strengthen her musculature) and medications, all of which are documented in her medical history.  Upon determination that conventional treatment will not alleviate her problems, her physician has made a recommendation for breast reduction surgery and referred her for consultation with Dr. Castillo.

Our office submits a predetermination of medical benefits request to each of their respective insurance companies.  Jenny’s insurance company replies that the procedure of breast reduction surgery qualifies for benefits according to the limits/levels of her individual policy.  Jane’s insurance company replies that they require additional proof of medical necessity (unsatisfactory response to conventional therapy) and attaches a list of their requirements prior to breast reduction approval.

Both women have the exact same medical situation but Jenny’s efforts have resulted in a positive reply from her insurance company and she is able to schedule her surgery right away.  Jane is faced with the prospect of enduring her symptoms while she begins the medical documentation process or absorbing the financial responsibility alone.

I wish I could say that we’ve never experienced these scenarios, but we have.  It’s important to not ignore your medical symptoms and to seek professional advice from your physician.  The “paper trail” of medical necessity can be the difference between obtaining relief versus continuing on the spinning wheel of discomfort.  Arming yourself with the documentation you need for medical insurance coverage just makes good sense while suffering in silence is counter productive.

Do you have questions regarding insurance coverage or medical necessity?  If so, please don’t hesitate to give us a call at 800-252-7123.  We are strong advocates for our patients and are happy to help.

 

Ask Our Expert: Options For Males With Large Breasts

Friday, June 14th, 2013

 

Does Dr. Castillo offer a procedure for males with large breasts?

Dr. Castillo:  Correcting large male breasts is one of the most life changing cosmetic surgeries for men. For some men, having large breasts significantly affects the way they see themselves, resulting in a depletion of self-esteem.  It changes the way they relates physically and emotional to others.  It changes how they play with their children.  It reduces their level of activity and willingness to be social.

BEFORE Male Breast Reduction

Does this happen to a lot of men?

Dr. Castillo: Yes, much more often than one would think.  It is actually quite common.  It can be related to genetics, hormones, or higher weight. It is easy to correct with a combination of breast liposuction and the surgical removal of undesired tissue through a small incision.

AFTER Male Breast Reduction Surgery by Dr. G.D. Castillo

When can they return to work?

Dr. Castillo:  Light work duties can be resumed with in two to four days after male breast reduction surgery.

What are the age limits for male breast reduction?

We perform breast reduction by liposuction as early as age 14.  If a young male (age 14 and up) has had an endocrinology study completed that indicates the need for surgical tissue removal then in those instances surgical breast reduction would be performed.

 

What makes you qualified to perform these procedures:

Dr. Castillo:  I am the only triple-board certified cosmetic plastic surgeon in the region and have been performing cosmetic surgery for more than 3o years. I am the past president of the American Society of Liposuction Surgery and the past-president of the American Academy of Cosmetic Surgery.

G.D. Castillo,M.D., FACS
Cosmetic Plastic Surgery Center