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Concern About Insurance Coverage for Small/medium Frame

asked 9 months ago by scarebear in VA
Latest answer by John Whitt, MD
Question viewed 229 times
Tags: amount, candidate, F cup, insurance

I'm 5'6", 132-140lbs(muscle), w/32F/34DD/F breasts. I've always had pain in my back, shoulders & neck. I've seen a chiropractor, work out very regularly (been concentrating on back w/personal trainer), & have great bras (sports & other). I also had a surgery consult 5 yrs ago. Carefirst says for 131-200lbs 500g/breast must be removed via lipo/reduction to qualify - 400g if 130lbs or under! I am concerned this is too much for my size. Schnur says I should be ~370g. Can this be disputed by a doc?

8 answers to Concern About Insurance Coverage for Small/medium Frame

+1

Insurance Coverage For Reduction

Most insurance companies look at the weight of tissue removed in relation to body surface area. If the Schnur formula were used in your situation, the weight requirement would be a good deal less than 500 grams. I have, on occasion, been successful by involving state insurance commisioners when insurance companies were totally unreasonable. You might wish to check to see if this an option for you.
John Whitt, MD

Louisville Plastic Surgeon
+1

Insurance and breast reduction

Insurance companies have criteria that are somewhat arbitrary and as frustrating for physicians as they are for patients. The best answer I can give you is to get pre-approval but don't let the insurance companies dictate the size of your breasts. All the best, Talmage J. Raine MD FACS
Talmage J. Raine, MD

Chicago Plastic Surgeon
+1

Insurance Coverage for Breast Reduction in Small Frame

The insurance company sees breast reduction surgery as a matter of medical necessity. Therefore, they will ask to rule out other etiologies of neck, back pain prior to approval. This is why we often ask for evaluation by a primary care physician with x-rays, to confirm that there is no musculoskeletal cause to the pain. Secondly, they will look at your body mass index (ratio of your body weight and height) and compare this to your breast size. Each... more
Paul S. Gill, MD

Houston Plastic Surgeon
+1

Insurance coverage dodge......

Hello, Minimum weight removal limits are just another insurance company dodge to avoid paying for the surgery. Pain is relieved as other docs have indicated by both removal of tissue and re-suspension/lifting, so the minimum weight removal criterion is not valid medically. You might want to look into another insurance plan. It is hard to get insurers to re-consider these things. Best Regards, John Di Saia MD
John P. Di Saia, MD

Orange Plastic Surgeon
+1

Insurance and Breast Reduction Surgery

Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance. I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well). Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the large breasts. Supporting documentation is usually very helpful. Good Luck! more
Tom J. Pousti, MD

San Diego Plastic Surgeon
+1

Insurance coverage for breast reduction.

It certainly sounds as if you are a good candidate for breast reduction. Insurance coverage, unfortunately, can be difficult. First, find out if breast reduction is a covered procedure in your plan. If so, then a letter from your board certifed plastic surgeon to your insurance company on yor behalf will be important. Letters from other doctors recommending breast reduction will strengthen your case. Even with all of that, most insurance companies will not guarantee payment and may deny the... more
William H. Gorman, MD

Austin Plastic Surgeon
+1

It has been shown that breast reduction improves symptoms REGARDLESS of how much tissue is removed.

Insurance Coverage for Breast Reduction Article by George J. Beraka, MD Manhattan Plastic Surgeon 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... more
George J. Beraka, MD

Manhattan Plastic Surgeon
+1

Insurance coverage for breast reduction.

The criteria for insurance coverage for breast reduction include back pain, neck pain, shoulder ridges or grooves from bra straps, rashes or infection beneath the breasts (termed "intertrigo"), and may also include headache and numbness in the 4th and 5th fingers from bra strap pressure on the brachial plexus (nerves in your neck to your arms and hands). These are all subjective and every plastic surgeon elicits these from their patients. Chiropractic or family doctor assertions... more
Richard H. Tholen, MD, FACS

Minneapolis Plastic Surgeon

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