Is there an objective way to measure the weight of breast tissue?

Question

I would like to get a breast reduction covered by insurance. I wear a 32g or h or 34f or g. Admittedly, they don't look that big. But, they dig into my shoulders, cause back pain and racerback bras cause numbness and tingling in my fingers. I had a consultation and the surgeon said I was a good candidate, but that he worried I'd be unhappy with the size after removing enough to meet insurance requirements. Insurance denied me based on that even though I met all the other requirements.

Leland Deane, MD, FACS · Answer

This is an awkward time in reduction coverage. The insurance companies find it most beneficial to them to rely on 'weight only' requirements based on your height and weight. Supportive evidence regarding rashes, pain, etc are relatively soft in effectiveness for coverage. The real issue is that POSITION of the breast tissue is very important, and, even though there is some mention of this in our literature and plastic surgeons see great results from 'low weight' reductions, the insurance companies will not recognize this. 
I tell all my patients that the benefit relies not only on removing weight but on a breast lift which is part of the procedure.
Bottom line: do not sacrifice shape from excessive weight removal. If your surgeon cannot get approval through the appeal process, you may need to pay out of pocket for the procedure you need.

Ellen Ozolins, MD · Answer

Thank you for the question. Based on what you’re describing, it does sound like your breasts are causing physical symptoms. These are all common reasons why breast reduction surgery may be a good option to relieve your discomfort. But, it's difficult to determine exactly how much tissue would need to be removed without seeing your photos or doing an in-person consultation. However, many insurance companies use the Schnur Sliding Scale as a guideline for how much breast tissue should be removed to help improve your symptoms. This scale correlates your body surface area with the amount of breast tissue that needs to be removed. If insurance denies coverage, you may have the option to appeal, especially if you can further document your symptoms and physical limitations.

Irena Karanetz, MD · Answer

Hi,

Thank you for the question.

Based on what you are describing, it does sound that you have large/heavy breasts causing physical symptoms, and breast reduction may be an option for you.  However, it is difficult to tell without seeing the photos and/or in person consultation. 
 
Schnur Sliding Scale is a scale used by many insurance companies as a guideline for how much breast tissue should be removed in order to improve your physical symptoms.  In addition, most insurances in order to approve the surgery, will require for 1-3 letters of medical necessity (from your chiropractor, primary doctor, OBGYN, Dermatologist, etc) demonstrating that your physical symptoms due to large breasts are not improving with conservative management. 
 
The goal of breast reduction surgery it to make the breasts smaller and lifted, but also proportionate with the rest of your body.  It is reasonable to to expect full C/small D cup breast size after the breast reduction surgery.
 
I suggest that you seek an in person consultation with a Board-Certified Plastic Surgeon specializing in Breast Reduction surgeries to further discuss  your options, specific techniques, concerns and expectations.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.

I hope this helps.
Best regards, Dr. Karanetz
 
Dr. Irena Karanetz
Breast Fellowship-Trained
Board Certified Plastic Surgeon
Queens, New York
(516) 833 0309

Elizabeth Kiwanuka, MD, PhD · Answer

It’s frustrating to face insurance denial despite meeting many of the requirements for coverage. Your symptoms clearly indicate a need for a breast reduction, and it’s important to advocate for yourself throughout this process. Here are some steps you can take:
Appeal the Denial: Request a formal appeal from your insurance company. Provide additional documentation from your surgeon detailing your symptoms, the impact on your quality of life, and the medical necessity of the procedure. Your surgeon can also include a detailed description of the amount of tissue removal needed and the potential outcome.
Additional Documentation: Obtain supporting documentation from your primary care physician or any other specialists who can corroborate your symptoms and the need for surgery. This may include detailed notes on how your symptoms affect your daily activities and overall health.
Consider a Second Opinion: Consult another plastic surgeon for a second opinion. They may provide a different perspective on the amount of tissue that should be removed and offer additional evidence to support your case for insurance coverage.
Explore Alternative Coverage Options: Check if there are any other insurance plans or financial assistance programs that might cover the procedure. Sometimes, different plans or financial aid programs can offer support for necessary surgeries.
Document Everything: Keep thorough records of all communications with your insurance company, medical providers, and any appeal submissions. Detailed records can help support your case and ensure you have a clear path to follow.
It's important to continue advocating for your health and to gather as much evidence as possible to support your need for the surgery. Your surgeon can be a valuable ally in this process.

Gary M. Horndeski, MD · Answer

Prior to surgery, you can have a scan done which will determine the volume of your breasts. The volume in CC's equal grams. At size 32, even size G, are not that large of breasts. At size 32, each 100 grams remove corresponds to 1 cup size change. Often times, insurance requires a minimum of 500 grams removed which would correspond to 5 cup sizes. You would be better off paying for it yourself. The technique I recommend is The Bellesoma Method. This will reduce and reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. The weight of the breast is transferred to the underlying pectoralis major muscle resulting in pain relief without excessive reduction. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Connie Hiers, MD, FACS · Answer

Yes, we weigh the amount of tissue we remove in the OR with a scale. The pathologist also weighs the tissue again. The insurance company sees both weights.

Camille Cash, MD · Answer

If you are having issues getting insurance approval for your reduction you may want to look into treatments which could help your symptoms such as physical therapy.  If these do not help it may give you more proof to present to your insurance carrier that a reduction is medically necessary.  Another option is to explore reduction and pay out of pocket.  This way you have more control over what you want in the end and many surgeons can connect you with financing options.

Mats Hagstrom, MD (license on probation) · Answer

It may be helpful to understand the logistics of surgeons excepting insurance reimbursement for this procedure.
As a general statement, patient who have symptoms of excessively large breast should have breast reduction surgery covered by insurance.
If a surgeon chooses to accept insurance reimbursement, then that reimbursement comes with an understanding that the surgeon is not allowed to build a patient More than the insurance reimbursement amount.
In other words, the surgeon will get paid only what insurance pace and no more and cannot charge the patient the difference.
What insurance reimburses for breast reduction surgery in comparison to what most surgeons would charge as a cash procedure can be at tenfold difference.
Insurance reimbursement may give the surgeon $1400 for breast reduction surgery.
This has to cover all of the expenses for the surgeon, including running their office and seeing the patient after surgery. The cash price for breast reduction surgery is going to vary significantly.
Surgeons fees are probably around $10,000 some charging more.
The drawback to having this done as a cash procedure is that the procedure is quite lengthy, and the operating room and anesthesia cost becomes significant.
It’s not just the compensation for the surgeon, but the cost for the facility and potential after care.
You may be able to spend one night in the hospital if the procedure is done as an insurance based procedure.
It’s definitely possible to do it as an outpatient procedure and that’s probably how most breast reductions are done today.
 Recognize that there’s a financial gain for most plastic surgeons to not accept insurance.
The best way to the procedure will deliver is to see lots of before, and after pictures of previous patients who had very similar body and breast characteristics to your own.
This shouldn’t be your first rodeo and if they have experience, they should have at least 100 sets of before and after pictures to show you.
There should be no Misunderstanding of what your results are likely to look like.
Without seeing pictures, we can’t really give you an assessment.
Cop size is universally unreliable and subjective when it comes to determining breast size.
Most insurance companies want us to remove about a pound of tissue.
 If you know what a pound of butter looks like that gives you a general idea. 
If the surgeon wrote a low estimated weight to be removed, then the insurance company is going to deny the authorization.
All the surgeon has to do is increase the estimated amount of weight.
There’s always some issue if the surgeon requests authorization for an estimated amount of weight and then removes less tissue during surgery.
I’ve never seen insurance company Reverse authorization based on insufficient tissue removal, but it could happen.
I think you should try to read between the lines and see if your surgeon is trying to get more income, which most likely is going to be the case.
I hate to be cynical about this, but that’s how the world works.
For insurance based breast reduction surgery, select surgeons who typically do lots of insurance based breast surgery to start with.
This may include plastic surgeons who do most of the breast cancer reconstruction in your community.
Those plastic surgeons tend to be a really good at breast Surgery in general.
If you want to stay with your current provider, then ask your provider to show you lots of before and after pictures of patients who had the procedure done as a cash procedure or as an insured base procedure who had similar size breast to you in the before, pictures.
Bring pictures of your body with you to use as a reference during all consultations. 
Recognize there is a financial gain to not accept insurance, but this makes the operation incredibly expensive for the patient who has an entitlement to have the procedure from their insurance.
It’s a covered benefit.
It seems fair to me that the surgeon should be able to charge the difference from the patient, but that’s not how the rules are set up.
Sometimes a small amount of liposuction on the side of the breast on the chest wall can be done to improve the breast reduction outcome, and sometimes that can be seen as a cash cosmetic procedure that can alleviate the sometimes insufficient compensation to motivate good plastic surgeons to take insurance reimbursement.
 Generally speaking, it should be straightforward and surgeons should either accept insurance or not accept insurance and then serve as patient advocates and do what’s in the patient’s best interest.
Sometimes the world just isn’t like that.
I think once you recognize that surgeons may put their financial gain ahead of your well-being from time to time.
If you sense, that’s the case then simply consult with other plastic surgeons until you find someone who is an advocate for what’s best for you.
Plastic surgeons have the right to not accept insurance and for those providers Cash is the only way to go.
I think if a plastic surgeon is going to accept insurance based work, then I need to recognize that that’s what the decision has been and they shouldn’t try to move patients from one category to the other on a case by case basis.
I can’t speak I’ll behalf of what’s really happening in your situation but I know this comes up regularly and I personally would much rather make $10,000 than $1000.
When I started practice, I gave myself two rules to always follow.
The first rule was to always be a patient advocate first.
That means one in doubt I would make decisions based on what I would want for my family.
The second rule was to make a living for myself.
The first rule always trumped the second rule and that’s how I’ve tried to practice. 
Be an advocate for your own needs.
You have medical insurance and a breast reduction should be a covered benefit.
It’s always a good idea to have a few consultations before selecting a provider and I suggest you do just that.
Best,
Mats Hagstrom MD

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