Shoulder grooving as condition for breast reduction surgery under Cigna? Any way around that? What if you're young?

Question

Hi, I'm wondering if anyone has dealt with Cigna recently regarding breast reduction surgery. They have a condition for approval that "shoulder grooving" be present. What does that entail? How deep does the groove have to be? I'm only 33, but am 32e, I feel like this shoulder grooving condition rules me out since I don't where thin strapped bras and am pretty young to have had such structural changes develop.

Gerald Minniti, MD, FACS · Answer

Hello,Unfortunately, insurance coverage for any procedure that spans both medical and cosmetic issues like breast reduction are becoming more difficult to obtain. Most insurance companies demand substantial evidence of alternative treatments and have slashed payments for both in-network and out-of-network surgeons. Surgeons that have substantial expertise and skill just don't take insurance anymore. I recommend looking at financing your surgery instead.  Go visit a few ABPS certified/ASAPS member surgeons that specialize in breast surgery. Best of luck!

Andre Aboolian, MD · Answer

You can still qualify for breast redcution to be medically necessary because shoulder grooving is one of the many conditions that you must have to be diagnosed with medially necessary macromastia.  If you read the requirments from Cigna or your plan it will list all the requirements.  Also, everyone with macromastia has some degree of shoulder grooving.

Robert L. Kraft, MD, FACS · Answer

Cigna enumerates a variety of underlying symptoms. You need not have all. Bra strap grooving results from the shoulders being cut by the weight and tension of the bra. There are other criteria which can be fulfilled in lieu of it.  You must have attempted and failed conservative medical management. They want you to have completed a course of physical therapy or chiropractic for at least three months.  That's the way they limit surgery to those would have the resources and time to go through this charade when everyone knows that the only viable treatment is surgery.

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems your disproportionately large breasts have caused.  Breast reduction tends to be one of the most patient pleasing operations we perform.

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. Assuming you meet the majority  insurance companies "criteria",  it is unlikely that the absence of shoulder grooving will lead to denial of authorization.

In regards to outcome of the planned procedure, the most important   decision you make will be selection of plastic surgeon. I would suggest starting with the American Society of Plastic Surgery and/or the Aesthetic Society of Plastic Surgery to obtain a list of well experienced board-certified plastic surgeons.

Then, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery. ***Ask to SEE lots of examples of their work AND preferably speak/see patients who have had similar procedures done.

Best wishes with your breast reduction procedure; hopefully you will be very pleased with the outcome of the procedure performed.

Shoulder grooving as condition for breast reduction surgery under Cigna? Any way around that? What if you're young?

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