Documentation of Back Problems for Breast Reduction Insurance Coverage?

I appreciate the answers I got for my question about getting a breast reduction for my size H breasts and I have taken the advice from my answers. I have a consultation with a surgeon and I also have talked to my insurance company who says they cover with a PA. What would be advisable to do if they want documentation of my back problems and I can't go to a chiropractor because it's not covered by my insurance plan?

Doctor Answers (11)

Documented back pain can support insurance claim for breast reduction

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Back pain and strain is 'the' issue concerning the need for breast reduction and in the past was considered the primary indication for insurance coverage. Many insurance carriers rely on documentation of this finding in the predetermination process. The best documentation is from physical therapy, chiropractic therapy, or an evaluation note from an orthopedic or sports medicine physician. Documentation and support of the predetermination process can also come from your primary care physician, or even your OB-Gyn. Each individual carrier and plan under a particular carrier may have a different set of 'rules' to go by. Often the insurance company will share their criteria to help you prepare so it is helpful to call.

Best of luck,

peterejohnsonmd


Chicago Plastic Surgeon
4.0 out of 5 stars 27 reviews

Doctor Recommendations help with insurance coverage

+1

Insurance Criteria for Breast Reduction Varies between Companies but recommendations from your primary care doctor, your gynecologist and the Plastic Surgeon should be enough (the more the better) without having to go to a chiropractor.
Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.
The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.
Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth).  In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities.  Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month.  Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance though insurance criteria are becoming more and more restrictive.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 44 reviews

Breast Reduction and Insurance Coverage?

+1

Thank you for the question.

Your primary care and/or psychologist  may be helpful in documenting “back problems” and referring you to the appropriate spine specialists.  These physicians will hopefully be  covered through your insurance plan.

Based on your description the hoops you are jumping through will be worth the trouble;  breast reduction surgery is one of the most patient pleasing operations you perform.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 710 reviews

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Insurance coverage for breast reduction.

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Insurance Coverage for Breast Reduction
View Edit

Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
Contact the doctor
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2) Very big reductions (like from an F cup to a C cup) will usually be covered.

3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9) Don't give up. If the first request is denied, demand an appeal.

10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

Helpful?Last modified 24 days ago

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast Reduction

+1

This can be done by your family practice or internist. You may also see physical therapist that can document this for you. This is important but what is most important is your height and weight to determine the body surface area which will determine how much breast tissue will need to be removed for this procedure to be deemed medically necessary.

Good luck.

Farbod Esmailian, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 31 reviews

Documentation of back pain to support insurance coverage of breast reduction

+1

Frequently your primary care physician or gynecologist are willing to write a course of physical therapy for management and treatment of back pain, This course of physical therapy will establish a record of back pain and the need for treatment.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 44 reviews

Back pain documentation for breast reduction

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If you can truly document back and neck pain this would be helpful. Care documented by an orthopedist for several months would be helpful. If the symptoms do not improve with exercises that they recommend or physical therapy, you may be able to get approval.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Back pain documentation

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Since your insurance company is calling the shots it is best to find out from them what they mean by "documentation of back pain". It may be as simple as your plastic surgeon saying that you have back pain or as complex as an Orthopedic evaluation, scans and physical therapy.

John P. Stratis, MD
Harrisburg Plastic Surgeon
4.5 out of 5 stars 17 reviews

Breast Reduction for Back Pain

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It is unlikely that your ins. co. would require a chiropractive evaluation to document your back. Most ins. cos. want to see a failure of back pain correction with conservative measures (PT,etc.). Check with your ins.co. to see what their requirements are. Your family physician or an othopedist may be of help.

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Insurance documentation varies

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Hi Karim,

Every insurance company will have different requirements for documentation. Make sure you have asked specifically what they want and have it in writing. The best place to start would be your regular family physician that is on your insurance plan. If you need more evaluation or documentation then he or she can refer you to another physician on the insurance plan.

Best Wishes

Dr. Peterson

Marcus L. Peterson, MD
Saint George Plastic Surgeon
4.5 out of 5 stars 13 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.