Using Your Insurance for Breast Reduction and Breast Reconstruction

Will my insurance cover this?

It is usually the first question we are asked, and for many women the answer is yes. Breast reduction and breast reconstruction are frequently medically necessary rather than cosmetic, and insurance plans do cover them.

Our practice is out of network, which simply means we are not contracted with your insurance company. It does not mean your surgery cannot be covered. Many of our patients have had their surgery paid for through the out-of-network benefits on their PPO plans, and our team walks the insurance process with you from the first phone call to the day of surgery.

What being out of network means for you

Most PPO plans include out-of-network benefits, and they exist for exactly this situation: seeing a specialist who is not in your plan's network. What you pay comes down to three numbers.

• Your out-of-network deductible, which is what you pay before your plan starts to contribute.
• Your coinsurance, which is the share of the cost you are responsible for once that deductible is met.
• Your out-of-pocket maximum, which is the most you will pay in a plan year before your plan covers the rest.

These figures are usually different from your in-network ones, and they vary a great deal from plan to plan. That is why we verify your benefits and go through your estimated costs with you before you decide anything. You should never be surprised by a bill.

If you have an HMO, out-of-network care is generally not covered except in an emergency. Please still reach out to our office to discuss it. We would rather tell you honestly where you stand than leave you wondering.

Dr. Li has formally opted out of Medicare and is not a Medi-Cal provider, so neither plan can be billed for your care. You are still very welcome to see her privately. Many patients in this position choose to pay for a consultation so that an experienced plastic surgeon can review their medical records and history in full and give them a clear surgical plan. For Medicare patients, this is arranged through a private agreement that we will go through with you before your visit.

How we work with your insurance

This is the part few practices explain, and it is where experience makes the difference.

We verify your benefits

Before your consultation, our team contacts your insurance company to find out whether your procedure is a covered benefit and exactly what your out-of-network benefits are.

If we can work with your PPO plan, your consultation with Dr. Li is free. There is no out-of-pocket cost for that visit, so you can find out exactly where you stand before committing to anything.

We build your documentation

Dr. Li's consultation note typically runs five to six pages, and you receive it as a PDF. Together with your measurements, photographs and history, it becomes the medical case that goes to your insurance company. A thorough, well-documented case is the single biggest factor in an approval.

We submit your pre-authorization

Our team prepares the request, submits it, and follows up. When your insurance company asks for more information, we respond quickly, because delays are what stall most requests.

Dr. Li speaks to the medical director

If your insurance company questions or denies your request, they may allow a peer-to-peer review, which is a direct conversation between Dr. Li and their medical director. This is the moment where having an experienced surgeon matters most. Dr. Li has been making these calls for many years, and she knows what that conversation needs to cover.

We support your appeal

A denial is a decision, and decisions can be challenged. You have the right to appeal, and depending on your plan you may also be entitled to a review by an independent reviewer outside your insurance company. We will help you understand your options.

Is the consultation free?

If we can work with your PPO plan, yes. Your consultation with Dr. Li is free, and there is no out-of-pocket cost for that visit.

Some patients come to us for a different reason. They are already working with an in-network surgeon, or their plan will not cover our care, but they want an expert opinion before making a decision they cannot undo. Dr. Li is happy to provide a paid second-opinion consultation for these patients. She will review your medical records and history in full, perform a physical evaluation and give you her recommendations in writing, in the same five-to-six-page note every patient gets, so that you understand your options and can ask your own surgeon informed questions. Patients have told us they found this extremely helpful.

The same applies if you have Medicare, Medi-Cal, or an HMO such as Kaiser. We cannot bill those plans, and the consultation is an out-of-pocket cost, but it still gives you Dr. Li's full review of your records and a clear surgical plan. Dr. Li has seen several patients in exactly this position and they have all been very happy that they got a second opinion. In some cases, Dr. Li may be able to refer you to a plastic surgeon or other physician she trusts who is able to work with your insurance. Reach out to our office to discuss it.

What to ask your insurance company

You can start today. Call the member services number on the back of your card and ask:

• Is this procedure a covered benefit on my plan?
• Do I have out-of-network benefits?
• What is my out-of-network deductible, and how much of it have I met this year?
• What is my out-of-network coinsurance?
• What is my out-of-pocket maximum?
• Is prior authorization required?

Before you hang up, note the date, the name of the person you spoke to, and the reference number for the call. It is worth keeping.

Where to go next

• Insurance coverage for breast reduction, with Dr. Li's free step-by-step guide
• Insurance coverage for breast reconstruction

Call our office at 626.888.9728 to schedule your consultation, or request an appointment online.

The information on this page is general and is not a guarantee of coverage. Every insurance plan is different, and coverage decisions are made by your insurance company.