What are the odds of getting my Aetna HMO plan to approve a much needed breast reduction?

Question

I can't say that I have the sad story of growing up with large breast as this was not the case for me. My breast showed up at the age of 21during my 1st pregnancy. I went from a 34C and as of today I am now a 36K. After giving birth I went back to the doctor several times to to ask for something to help them return to their original size but nothing could be done. I have suffered severe back pain and diagnosed with a Degenerative Disc Disorder. Any advice would be greatly appreciated!

Ronald J. Edelson, MD · Answer

If anyone qualifies for breast reduction coverage under insurance, I would say that would be you.  You should contact your insurance company to find out the steps necessary to get it covered.  If you have an HMO you may need a referral to a plastic surgeon from your regular doctor.

Jaime S. Schwartz, MD, FACS · Answer

I appreciate your question.We have to look at all of your symptoms such as the back, neck and shoulder pain as well as any skin infections you might have.From what I see, you are a great candidate and insurance typically covers this for my patients.The best way to assess and give true advice would be an in-person exam.Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.best of luck!Dr Schwartz

Brian K. Reedy, MD · Answer

Thank you for your question and photos! Not every insurance will cover a breast reduction but it is worth calling your insurance company to see what your policy is.  Once you get the information from your insurance I would then consult with a Plastic Surgeon of your choice.  The surgeon would be able to give you a hands on assessment and let you know if he/she could meet insurance guidelines. If guidelines can be met the next step would be for your surgeon to get authorization for the surgery. Best of Luck!

J. Jason Wendel, MD, FACS · Answer

Thank you for your question about breast reduction.It is probably best to contact your insurance company and ask about specific criteria for breast reduction. Then, gather information and go for a consult.To be sure, see two or more board-certified plastic surgeons in your area for a full and complete evaluation to make sure you are a good candidate and that it is safe for you to have breast reduction or related procedure.I hope this helps.

Miguel Delgado, MD · Answer

It is very possible that your insurance will cover breast reduction surgery for you, it will depend if it is a covered procedure under your policy. Usually HMO's require to see a participating doctor in their plan, and usually a referral from your general physician. You might start there and request a referral to a Board Certified Plastic Surgeon. Good luck.

C. Bob Basu, MD, MPH, FACS · Answer

Every insurance plan has their 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. BasuHouston, TX

Tom J. Pousti, MD · Answer

Thank you for the question. Based on your description and picture, you sound like you may be a good candidate for  breast reduction surgery; of course, much more information is necessary to provide you with definitive advice

Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient  pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link, helps. Best wishes.

Sugene Kim, MD, FACS · Answer

Breast reduction may or may not be covered depending on your insurance 
carrier and your breast size. Please check your insurance policy to see 
whether breast reduction is a covered procedure. Often times, insurance 
company will dictate how much breast tissue to be removed. Please visit 
an experiences, board-certified plastic surgeon to learn about the 
procedure, its cons and pros, benefits, and alternatives. Please contact
 your insurance carrier to learn about inclusion and exclusion criteria.
 Best wishes.

Michael K. Obeng, MD, FACS (license on probation) · Answer

Hello, and thank you so much for a great question.  It is always best to be examined in person by a board certified plastic surgeon for the most accurate information.It is rare that I see photos alone and can say with a great deal of certainty what must be done.  However, you are different.  It seems very clear to me that not only do you need a breast reduction address associated health issues, but you should most certainly qualify under insurance guidelines.  HMO insurance is a bit trickier than a PPO plan.  PPO insurance gives you the right to visit whatever provider you choose- with out the need of lengthy referrals.  An HMO plan requires that you see physicians that have been designated previously by your carrier. (IN NETWORK COVERAGE ONLY) A plastic surgeon is a specialist and will probably require a referral.When you do find a provider, they will examine you, take detailed notes describing any complications your breasts may cause you and describe how your large breast size is affecting your over health quality.  The doctor will also take photos.  He/she may also prescribe medications to clear associated symptoms traditionally caused by large breast (skin irritation under the breast, or infection) to see if this can provide relief, without surgical intervention.  This information will be passed along to your insurance carrier, who then will make the ultimate call as to whether you meet their specific criteria for breast reduction coverage.  I have had patients denied, but don't fret- there is an appeals process if you keep pushing.  Note some insurance plans have specific clauses excluding breast reduction surgery altogether. Call the customer care number on the back of your insurance card to get this information.Also, October is traditionally open enrollment for most insurances- so it is the perfect time of the year to shop for a new plan if you do not currently have a plan that will cover you, or makes qualification very difficult. A breast reduction may certainly give you much needed relief.  Best of luck on your journey.  I hope I was helpful.Best,Dr. Obeng

Talmage J. Raine, MD, FACS (retired) · Answer

Unfortunately your question is more of an insurance contract issue than a medical issue. Most insurance companies are relying on a formula (Schnurr scale) that involves weight, body surface area (BSA) and estimated amount of tissue to be removed. You should talk to an insurance representative. All the best,Talmage Raine MD FACS

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