Will united healthcare cover a breast reduction and how small with they require me to go?

Question

I am 5'5" 145 pounds and in a 32G bra, 25yrs old. I am currently pregnant with my second child so I am sure they will enlarge even more after I give birth as they did after my first.

Larry S. Nichter, MD, MS, FACS · Answer

Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions. This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive
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Gary M. Horndeski, MD · Answer

Thank you for you question,   The Bellesoma Method is a current technique to lift and/or reduce breasts without using implants or the ugly vertical scars.  The incisions are hidden around the areola and in the inframammary crease. The vertical incision has been completely eliminated. The areola incision heals almost invisibly due to the fact that there is hardly any tension on the closure. With this particular technique, ducts are preserved along with nerve supply maintaining nipple sensation and the ability to breast feed. Because the breast is reshaped internally and is secured to your chest muscles, upper pole fullness is possible without an implant. Attached is a patient who underwent The Bellesoma Method. Please note that her tissue was used to create upper pole fullness and cleavage without any foreign materials (mesh, implants, etc).  Unfortunately, we do not accept insurance for breast reductions.  Dr. Horndeski does not remove enough breast tissue to meet insurance criteria.  Instead, he utilizes the breast tissue to reshape the breast.  It is a proprietary technique that only surgeons that have been trained by me can perform. I hope this helps. Best wishes and kind regards, Dr. Gary Horndeski

Kenneth Hughes, MD · Answer

Breast reductions which are medically necessary i.e. you suffer back, shoulder, and neck pain with documented medical attention) are typically covered by medical insurance. If not, your insurance company may try to deny you based upon a lot of things such as weight, lack of enough tissue that should be removed, lack of symptoms, and lack of previous medical management.
Read United Healthcare's certificate of coverage. Determine what medical information is required for them to provide a preauthorization or predetermination of benefits.  
Seek consultation with a board certified plastic surgeon who can evaluate your medical condition and assist you with obtaining a predetermination of benefits.

Tom J. Pousti, MD · Answer

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery; this operation tends to be one of the most patient pleasing operations we perform. Based on your description, it sounds like you may be an excellent candidate for the procedure.  
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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. 
Also, prepare to be persistent when dealing with health insurance companies. I hope this helps. Best wishes.

Steven Wallach, MD · Answer

You can first start by contacting your insurance carrier and determining what their criteria are for coverage. Then go see a plastic surgeon. Good luck!

Daniel Krochmal, MD, FACS · Answer

The best thing to do is to contact your insurance company and see if breast reduction is a covered benefit in your plan.  Next, I would consult with doctors within your insurance network who can guide you through the rest of the process, and the optimal timing given your current pregnancy.Best,Dr. Dan KrochmalMAE Plastic SurgeryNorthbrook, IL

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Unfortunately, dealing with insurance companies is often a challenging task. Your best option to see if your procedure is covered, is to contact your insurer to get details about coverage and requirements before approval for surgery (as you are doing). Given the difficulties of dealing with insurance, you can consider paying out of pocket for the surgery. For our patients, the out-of-pocket expenses for an insurance plan often approximate (or even exceed) the cost for the procedure. You can then obtain documentation from your surgeon to attempt to get reimbursement from your insurer. Any treatment plan should be based on a detailed discussion with equal input from both you and your surgeon.   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.   Preoperative visualization and surgical simulation with the Crisalix system may help with your decision. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation in person with a qualified board-certified plastic surgeon. Good luck! 
Best,
  
Jon Ver Halen, MD FACS 
  
Harvard educated plastic surgeon

Will united healthcare cover a breast reduction and how small with they require me to go?

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