Breast reduction and Insurance Coverage?
As you have found, insurance companies do not want to make it easy for patients to receive even covered benefits.
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 saying a well-trained/experienced board-certified plastic surgeon.
Continue to be persistent.
Insurance coverage for breast reduction.
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.
Helpful?Last modified 24 days ago
Insurance Coverage for Breast Reduction
This is a typical technique for some insurance companies to deny coverage eventhough they list breast reduction as a benefit when they sell you the insurance plan. The details will always get you with insurance companies. They will always win the shell game. One option would be to ask your plastic surgeon which insurance company understands the benefits of breast reduction the best in your area. If you have the ability to switch to that company, then you will have a better chance at getting coverage. Just be careful to not get stuck with pre-exisiting condition clause. Otherwise, just list out the criteria required by your current insurance company and try to meet them as best as possible.
Breast reduction coverage
I would recommend a physical therapist. They may be able to recommend back strength exercises which may help alleviate your back pain. After trying a physical therapy regimen they should be able to write a letter on behalf supporting the need for a breast reduction.
Managed care and insurance PA for breast reduction
This is a technique the insurance companies use called "rationing by hassle'. The more they hassle you, the less likely you will be inclined to undergo the surgery or force you to pay for it on your own.
Breast reduction requirements for conservative therapy
Every insurance has different requirements. It APPEARS yours is playing the kick-the-can-down-the-road delay tactic of "an adequate trial of conservative therapy" for 6 months or so. They hope that if you can document you were fitted for a new bra, saw several back specialists etc either you pain got better, you gave up on having the operation, or you switched insurance plans.
The best advice on the best course of conservative therapy would be your Plastic surgeon. Ask him/her what ids the best way to document this.
Breast reduction authorization
Breast reduction surgery has become tougher and tougher to get approval for eventhough patients clearly show improvment in quality of life after the procedure. I would recommend an orthopedist to evaluate you .
Breast reduction coverage can be difficult
You have taken the right first step to getting your breast reduction. Insurance companies have thrown a lot obsticles in your way to getting surgery. They want to see if you have done none surgical treatments that might make your symptoms better. This is why they ask for the alternative methods prior to surgery.
I would recommend a physical therapist as the person to help you with non surgical alternatives. After a reasonable amount of time, if you do not get better then you can qualify for surgery. Make sure a good record is being kept on your progress.
Breast Reduction Insurance Coverage
The situation you describe is a common ploy used by insurance companies to delay coverage or dissuade you from proceeding. Even though PT, chiropratic care, etc. are not going to result in any benefit if you pain is coming from your breast hypertrophy, you are going to need to play the game. I would suggest that you see an orthopedic surgeon who specializes in backs. If he/she feels that your pain is going to corrected only by a reduction, then the insurance company is probably going to have to comply.
Coverage for breast reduction
First, you should go to your family Dr and tell him/her what complaints you have and let them document them. They can refer you for physical therapy or orthopedic evaluation. That will all be documented in the record. Also have them document that you are wearing a proper bra(if indeed you are). Once you do these things, if they fail you can now have your family Dr. document that the conservative treatments have failed and refer you to the plastic surgeon.