Documentation of Back Problems for Breast Reduction Insurance Coverage?

Question

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?

Larry S. Nichter, MD, MS, FACS · Answer

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.

Farbod Esmailian, MD · Answer

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.

Otto Joseph Placik, MD · Answer

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.

Tom J. Pousti, MD · Answer

Thank you for the question.

	Your primary care and/or psychologist  may be helpful in documenting &ldquo;back problems&rdquo; 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.

Peter E. Johnson, MD · Answer

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

Steven Wallach, MD · Answer

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.

John P. Stratis, MD · Answer

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.

Marcus L. Peterson, MD · Answer

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

Peter A. Aldea, MD · Answer

Why not see a MEDICAL back specialist (Orthopedic or Neurosurgery) who may even be on your insurance panel? If they are not OR if your insurance company insists on a chiropractor, PAY HIM OUT OF POCKET (the way you would pay when you take your dog to the vet, pay your electrician, plumber etc) . I assure you that whatever the chiropractor may charge you would be much cheaper than if you had to pay the cost of your justifiable Breast Reduction.

George J. Beraka, MD (retired) · Answer

Insurance Coverage for Breast ReductionView Edit
Answer by George J. Beraka, MDManhattan Plastic SurgeonContact the doctor80% 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

Documentation of Back Problems for Breast Reduction Insurance Coverage?

Answers (11)

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