Breast reduction insurance coverage cigna


Question
My wife had been recommended by 2 different Drs. to get a breast reduction (she is 43). We have a Cigna PPO Health Insurance but they say that we need a DR to call them and have a peer to peer conference with them to justify the surgery. Is that a common practice? What kind of specialist should we contact to do that? What is the best way to get the surgery approved?

In managed care plans, like HMOs and PPOs, if a plan wishes for the PCP, physician, or specialist, to back up their treatment recommendation for coverage, the doctor must call the plan for a peer-to-peer review. Selected professionals on a peer review panel will talk with the ordering physician to determine if the plan can pay. Usually, the plan will pay if it can be determined that there is a medically necessary or justifiable reason for the surgery.

For instance, if your plan won't pay for cosmetic surgery, and this procedure is determined to be for cosmetic reasons, the plan may decide to deny coverage.

It would be best to have one of the recommending doctors call Cigna at it Peer Review phone number (on their website), to arrange for this review.

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