Q&A with a Health Benefits Expert
For my project, I interviewed the Head of Benefits at the company my parent works for, who is a 25+ year professional working with and administering employee health insurance programs.
I asked her the following questions to better understand how health insurance coverage works* and specifically what to know about health insurance coverage for breast developmental conditions.
*This information is specifically about employee health benefits in US companies/US health insurance providers. Coverage and benefits may vary significantly in other countries.
Have you heard of Poland Syndrome? If not, was it easy to find objective, reliable information?
I was not familiar with Poland Syndrome, but as with tuberous breast deformity, but I was able to find some some information using the internet/AI.
How Health Insurance Coverage Works
For an employer-sponsored health plan, who determines if a treatment or procedure is covered, the employer, the insurance company or the plan administrator, or some combination of these?
The employer generally determines this for a self-insured plan, with benchmark information provided by the Insurance Plan Administrator and broker.
How do health plans decide whether a treatment is considered cosmetic and when it’s considered medically necessary or reconstructive?
This determination is really made by the Plan Administrator or Insurer. All of the big insurers (Blue Cross, Aetna, United Healthcare, Cigna) use essentially the same definitions for these types of things. The primary difference being one is considered a structural defect or functional impairment vs a procedure performed primarily to improve appearance or symmetry.
Why might treatment for one congenital or developmental condition be covered while treatment for another developmental condition affecting the same area of the body is classified as cosmetic?
This depends on the Insurance Company’s definition of each condition and the clinical bulletins that they use to determine classification.
When a physician diagnoses a patient with a developmental condition and recommends corrective treatment, what typically happens when a request for coverage is submitted? What types of medical documentation are needed?
Typically, the Insurance Company relies on information provided by the physician. This includes:
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Plastic surgeon consultation notes
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Photographs
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Description of the specific deformity (constricted base, lower pole deficiency, areolar herniation, asymmetry, etc.)
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Proposed surgical technique and why it is needed
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Evidence that the condition is congenital/developmental.
When Coverage is Denied
If treatment for a diagnosed developmental condition is denied because it is considered cosmetic, what options exist to question or appeal that decision?
When coverage is denied an appeal can be made for a Peer to Peer review. The appeal can be made within 180 days of the denial and with patient clinical documentation from the physician supporting medical necessity. Most appeals are handled only by the Insurance company and does not include the broker or insurance provider. This helps to avoid inconsistencies (such as approving something for an executive that wouldn’t be approved for a individual contributor.)
Where do you think the biggest challenges are, awareness of the condition, documentation of medical necessity, health-plan language, the claims approval process, or something else?
The biggest challenge is in the documentation of medical necessity – Where it is not necessarily clear or straightforward, (gray area) it can be a difficult standard to prove.
Awareness and Change
Do you think greater awareness of under-recognized developmental conditions among healthcare providers, benefits professionals, insurers, and families could make it easier for patients to navigate healthcare and insurance? If so, how?
Definitely...... greater awareness and understanding of these types of conditions will make it easier and there are a lot of resources online, including this website, and utilizing AI that would be beneficial.
What would generally needs to happen for a health plan to reconsider how treatment for conditions such as tuberous breast deformity is covered?
It would take having major media coverage on it, such as a celebrity endorser, as well as people lobbying for changes to the standard of medical necessity (for example, to include/consider psychological effects as they do in some other countries).
If you could give one piece of advice to a teen who received a diagnosis like this (and parents) trying to understand their insurance coverage and what to do if denied, what would you want them to know?
Search out a doctor or doctor's office that will advocate for you with insurance and use AI resources to put together a case for medical necessity! Also, if a claim is denied by the Insurance Company, consider putting pre-tax money into FSA/HSA account to help cover costs.