I've been denied by my insurance for a breast resduction. My PCP still says I shouldn't be. What now?

I'm 29 5'11 and 220lbs. I've lost almost 30lbs and my breasts haven't shrunk an inch. They are starting to hinder my weight loss progress. I have shoulder,back and neck pain. I also have indents from the weight of my chest on my shoulders. I don't feel that the surgeon has done or spent enough time on my case. The letter she sent to my insurance was maybe 4 sentences and my visit maybe 10 min. She said I was denied but I haven't gotten a denial from my insurance yet? HELP!!

Doctor Answers 6

Insurance Coverage

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. Basu
Houston, TX

Insurance denial may be more than it seems.

Based on your stated height and weight, your surgeon would need to remove a MINIMUM of 955 grams per breast in order for you to qualify for insurance reimbursement. This is nearly two pounds per breast and spending "more time" on your case will not change your insurance company's requirements.

So either your consulting surgeon feels that removal of this weight of tissue per side would leave you "too small," unhappy with your size and proportion, or that you have too many risk factors or other concerns that would preclude safe surgery.

Symptoms ("indents," back pain, shoulder pain, neck pain, rashes, letters form your primary physician, etc.) don't really "count" any more, since pretty much every woman with large breasts complains of some or all of these issues. So the insurers rely on objective criteria (height and weight--BMI) to calculate the mandated minimum amount of tissue to be removed per breast in order to qualify for reimbursement ("coverage").

That formula is called the Schnur formula, and I have used it to plug in your height and weight and come up with 955 grams per breast. That's it, cut and dried, and the only discussion now is if that still leaves you with breasts that you can live with, size and proportion-wise. That requires more discussion with your plastic surgeon, or another one! Sorry, but that's why the insurance companies now rely on height and weight--everybody wants "help." Best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 239 reviews

Macromastia

Welcome to the new world of health care.I have noticed in the last several months that insurance companies are now denying coverage for conditions that were previously covered and were medically necessary.This may be the new world of ObamacareThe criteria are becoming harder and the rate of pay to the surgeons is going down to the pont that you will have a hard time finding a surgeon who will take the reimbursement because it is so low.These are challenging times to say the least.

Robert Brueck, MD
Fort Myers Plastic Surgeon
4.8 out of 5 stars 56 reviews

Denial

Find out what your insurance policy says about the next step. Most of them have an appeal process to follow unless there is a clause which excludes breast reduction, which is amazing when you think about it. If you work for a company that has a human resources department, then that can be an option for advice.

Edward S. Gronka, MD
Fayetteville Plastic Surgeon
5.0 out of 5 stars 12 reviews

I've been denied by my insurance for a breast resduction. My PCP still says I shouldn't be. What now?

The real issues are political and insurance losses. Your insurance is trying to make and save $$s. You chose the plan so it is on you for not understanding the restrictions and benefits provided by 'your' chosen health insurance..The PS provider can only request 'your' predetermination of benefits in letter form. NO insurance will write a guaranteed payment. So there is one issue. You could be saddled with a very very large bill post surgery. Plus the reimbursement of services has become so low that many PSs will not provide surgery for little if any acceptable payment. Plus the delays in stated payments. Final you can pay for the services out if pocket, sound bad but the fees for pre payment are less than you think... Good Luck... 

Breast Reduction

For your height and weight, there are normograms you can find on the internet which mention how much of a reduction you need to undergo for it to be covered by insurance companies.  Usually in the range of 600 gm - 700 gm per breast.  If your surgeon is able to remove this amount of tissue or more, your surgery should be covered by the insurance company.  Your surgeon needs to detail this information on his note to your insurance company.  Best wishes!

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.