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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.