I am 5'7" and last weighed at 210lbs, yes I know I am over weight. My bust is 40 H. I have been working out at my apartment's gym for a few weeks now. I have lost some fat and gained some muscle, and after losing some weight I gained it back without gaining the fat back (so in other words it is muscle) my natural waist is measured (this morning actually) at 34" and my bust is measured at 48", but all my doctor is concerned about is my weight. not my true body fat percentage. Any tips on how I could get my insurance approve my breast reduction?
Tips for Getting Insurance to Approve Breast Reduction?
Doctor Answers 19
There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.
1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.
2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.
3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.
Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.
The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!
Insurance coverage for breast reduction
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Ask Your Plastic Surgeon to PreApprove your Reduction.
Most use some variation of the Schnurr formula which calculates your BSA body surface area, and then each company has a certain number of grams required.
In many ways, this is fair to most. Little tiny women have a smaller grams requirement than big women, but it is somewhat proportional.
Ask your plastic surgeon to seek pre-approval for your breast reduction. Most are approved. For the few that are not, you can calculate how much weight you might need to lose to get approval, or with some plans, you might find the requirements too strict. In some cases, it may make sense to seek a cosmetic, or cash pay rate.
Breast reduction: insurance coverage
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.
A Prior Authorization Letter From Your Plastic Surgeon Will Help to Get Your Breast Reduction Approved
Breast Reduction is often considered medically necessary by insurance carriers and is therefore a covered expense. Before approval can be granted insurance carriers require prior authorization. This is a time consuming process that may take months.
The process begins with a consultation, followed by a prior authorization letter to the patient’s insurance carriers. This letter should include documentation of the patient’s history, symptomatology, pertinent physical findings, attempted non surgical management and anticipated amounts of tissue to be removed.
Supporting pictures as well as documentation of conservative management are also very important. This might include documentation of physical therapy, chiropractic care, the use of specialized support bras and non steroidal anti inflammatory agents.
The amount of tissue removed is one of the more important criteria used by insurance carriers. This number varies from insurance carrier to insurance carrier. Its often part of a height weight index. As a patient’s weight increases insurance generally require the removal of more breast tissue.
In your case, it would be unlikely for your insurance company to deny prior authorization for breast reduction. The size of your breast would meet most insurance company’s weight removal criteria, especially if you have appropriate supporting documentation.
If your considering breast reduction surgery, consultation with a board certified plastic surgeon who has experience in this area would be helpful in obtaining prior authorization for this procedure.
Tips for Insurance Approval for Breast Reduction
Here are some basics about Insurance Coverage Criteria for approval for Breast Reduction. Breast Reduction varies from insurance company to insurance company. In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc. They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems.. 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.
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
Breast Reduction - Insurance Coverage
It is nearly impossible to offer a guaranteed method of obtaining approval but if you have tried, and failed, a series of conservative techniques, then it may be reasonable to contact them. You'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery. You should, of course, meet with a few plastic surgeons to see what they recommend, and make sure you're informed about the procedure and its risks so that you can proceed knowledgeably.
Then, it may require some persistence. Start with contacting them via mail, and be sure to be involved in any followup phone calls, etc. Hopefully, this will wind up being successful and get you the results you want.
I hope that this helps, and good luck,
Breast Reduction Insurance Coverage?
Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.
Based on your description you may be a good candidate for breast reduction surgery; for physical and emotional reasons. The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're working with a well-trained/experienced board-certified plastic surgeon.
Insurance approval for breast reduction
I recommend that you go on line and download your insurance carriers criteria for breast reduction surgery. If you do not meet these criteria, I can guarantee they will not preapprove your surgery.
In general, many insurance companies will require that you have failed conservative treatment of your back, neck and shoulder pain before approving surgery. This includes no improvemnt in your symptoms with medication prescribed by your family doctor, no improvement after seeing a chiropractor/ physical therapist or after losing weight. A letter from your family doctor or chiropractor/ physical therapist would also help.
You will also need to see a board certified plastic surgeon who will need to submit a letter and pictures to your insurance company seeking approval.
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.