Can You Clarify "3 Months Conservative Treatment" for Breast Reduction Insurance Coverage?

Thank you for the question.

"Conservative therapy” may be defined differently by the various insurance companies. In my opinion, this is a simple stalling  technique,  since these measures do not significantly improve patients symptoms associated with breast hypertrophy.

Unfortunately, in order to have the breast reduction covered by the health insurance company it is necessary to jump through their hoops;  it will be in your best interest to determine what the specific company's definitions are by calling them directly.

Best wishes.

As you can see from all the notes  Plastic Surgeons do not necessarily agree with this insurance "requirement".

According to the insurance(s) I tried to clarify this with, they want to see a non-operative effort of three months to treat your complains of back-, neck-, shoulder pain. A physician (it can be a primary care Doctor, Chiropractor, Orthopedic Surgeon ) who prescribes  you a  "conservative" treatment  such as Physical therapy (we use here 6 PT sessions), chiropractic manipulation etc.

After three months  if you do not have a "long lasting improvement" of your symptoms you should qualify for this particular insurance criteria.

Remember your insurance carrier is your "sponsor" and therefore they can demand certain criteria to be met before they pay for your surgery. On the other hand your Plastic Surgeon will determine if you medically benefit from a breast reduction regardless of insurance coverage or not. That means sometimes that you will have to make a decision if you want to "pay out of pocket" for the procedure.

Welcome to the world of insurance coverage for breast reductions!  Many insurance companies in the NorthEast want documentation of neck and back pain brastrap grooving or intertrigo( rashes) fro 3-6 months.  This has to be documented by the treating physicians for the given problem. Yes, I know what your are thinking.  They want to make the process laborious and difficult so that fewer people can be approved.

Conservative therapy has different meanings to different insurance cos., but is essentially always a ruse to delay or avoid coverage.  PT, chiropractic care, and NSAIDS are among the treatments they refer to, but none of these nor any other "conservative therapy" will correct pain due to breast hypertrophy.

Hi Mindwhirl in Northern IN
 

Each insurance company is different and has different requirements before coverage would be considered for a surgical procedure.  The best thing for you to do is to work WITH a plastic surgeon you like.  You'll need that surgeon to submit a letter of proposed treatment, and you can ask him or her to help you find the answers to these questions.

Or you can find out yourself.  Contact your insurance company and find out EXACTLY what their criteria are for covering a procedure such as this.  They should be able to give you that info - although it may take a few phone calls and a LOT of persistence.

I hope that this helps, and good luck,

Dr. E

Insurance Coverage for Breast Reduction

Article by George J. Beraka, MD
Manhattan Plastic Surgeon80% 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.

 

Your insurance provider can detail exactly what they mean by "conservative treatment", but generally all of the examples you gave fit into that category. Usually they do not specify that you should have a single specific therapy, but a combination of therapies.

As far as medications, they certainly consider prescription strength medications more seriously than OTC. Also keep in mind that if you have problems with skin irritation and infection underneath your breast (a condition called intertrigo) that antibiotic or antifungal medications are best sought from your regular physician and any documentation you can provide of this should be sent to your insurance company as well. Best of luck to you.