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Concern About Insurance Coverage for Small/medium Frame

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?

Doctor Answers (9)

Insurance coverage for breast reduction

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Every insurance plan has there own unique criteria on whether they will cover a breast reduction.  More and more, we are seeing plans where a breast reduction is not a covered benefit.  If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage.  Some set the amount in relation to your BMI (height and weight).  Others require extensive medical records documenting neck pain, back pain, and history of rashes.   The other alternative is to opt for a breast reduction as a self-pay option.   Start by visiting with a board certified plastic surgeon to learn more about your options.

Best wishes,

Dr. Basu

Houston, TX

Houston Plastic Surgeon
4.5 out of 5 stars 101 reviews

Insurance Coverage For Reduction

+1

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.

Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Insurance and breast reduction

+1

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

Chicago Plastic Surgeon
4.5 out of 5 stars 7 reviews

Insurance Coverage for Breast Reduction in Small Frame

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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 insurance company has their own ratio, but it comes down to the fact that they will require your surgeon to remove an approved amount of breast tissue to obtain coverage.    If this tissue weight is not removed, coverage may not be given.     We are seeing an increasing numbers of denials if the BMI is too high in relation to the breast volume.    

We frequently offer our patients a cosmetic breast reduction if they are denied by the insurance company.   I find patients very satisfied with this method, as the focus shifts from meeting the insurance weight criteria, to reducing the breast volume , but maintain optimal shape, size, and symmetry.

Web reference: http://www.drpaulgill.com

Houston Plastic Surgeon
5.0 out of 5 stars 32 reviews

Insurance coverage dodge......

+1

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

Orange Plastic Surgeon
5.0 out of 5 stars 22 reviews

Insurance and Breast Reduction Surgery

+1

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!

Web reference: http://www.poustiplasticsurgery.com/Procedures/procedure_breastreduction.htm

San Diego Plastic Surgeon
5.0 out of 5 stars 626 reviews

Insurance coverage for breast reduction.

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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 claim based on how much tissue is removed.  Be prepared to be a "squeeky Wheel."

Austin Plastic Surgeon
4.0 out of 5 stars 14 reviews

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

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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 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.
 

Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance coverage for breast reduction.

+1

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 are perhaps helpful, but are neither necessary nor sufficient by themselves.

That is why the Schnur formula was devised (by Paul Schnur, MD, Mayo Clinic emeritus professor and past president of the American Society of Plastic Surgeons) as an objective method of calculating minimum amounts of breast tissue that must be removed per breast in order to relieve symptoms (and therefore qualify for insurance reimbursement). The formula is based on height and weight (BMI) and yields a firm number. One gram less than this and YOU get the entire bill for surgery, regardless of what you or your doctor say.

Your height and weight (using 132lbs) calculates to a weight of 350 grams per breast (needed to be removed). But wait, there's a "catch." Most insurance companies also mandate a MINIMUM resection of 400g per breast in order to qualify for reimbursement (regardless of height and weight), and you have told us that your insurance company is one of these. Regardless of the bra you are wearing, you should hold a 400cc implant next to your breast and imagine this amount removed from your breast. Actually, you must imagine what is LEFT BEHIND, as this is the size your new breast will be! If that is too small, then you need a breast lift or "cosmetic" reduction. Both of these operations are not covered by insurance, which is one reason insurance companies (most if not all of them) set the bar so high--you must have truly massive breasts in order for insurance to cover the reduction mammoplasty. And if you are a large woman, then your insurance company is essentially saying your breasts are too large because YOU are too large.

You doctor may appeal this minimum tissue amount because of your Schnur formula calculation, but you may still be denied. That is why insurance companies and HMOs have set these "rules." It avoids the subjective complaints, the need for doctor or chiropractic or physical therapy testimonials and letters, and makes determination a simple formula. YES or NO--no discussion.

Bottom line, if you really feel that removal of 400 grams per breast will leave you too small, then you really DO need a breast lift or "cosmetic" reduction, for which the cost will be yours. But with that also comes the freedom to choose exactly how much tissue you want removed--from skin only (a full lift removes 1/2 to 1 ounce of skin) to as much or as little additional tissue removed to give you the size you really want in a more perky, uplifted, and youthful skin brassiere. Best wishes!

Web reference: http://www.mpsmn.com/photogallery/breast-reduction-reduction-mammoplasty-5978

Minneapolis Plastic Surgeon
5.0 out of 5 stars 90 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.

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