My primary doctor will present my information to my insurance company. I am currently a 40/42 DD, 5'4, and 176 pounds. She didn't take photos and said that they weren't needed. What if not providing this proof to the insurance company doesn't work? It is clearly noticable that my breast are large, so I am guessing that this is why?
My Doctor Didn't Take Photos, So Does the Plastic Surgeon Do This? Will I Even Qualify?
Doctor Answers 16
Breast reduction pre certification request should include photos.
Insurance Coverage for Breast Reduction
Article by George J. Beraka, MD
Manhattan Plastic Surgeon
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.
Insurance coverage of breast reduction surgery
I personally review cases for insurance companies for coverage of breast reduction. The vast majority of them require a photo before they will preauthorize breast reduction surgery. I do not know what sort of insurance you have but I suspect the primary doctor submitted information to get permission for you to see a specialist i.e. a plastic surgeon. The plastic surgeon will then need to see and examine you and then send in a separate preauthorization for your actual surgery. Since the primary doctor is not doing the surgery he/she cannot really get the surgery preauthorized. The insurance companies role has morphed into a gate keeper that rations care to its subscribers and controls who they can see for what. That is why you will have to virtually jump through a number of hoops before they will cover the surgery. The original role was just to cover the unexpected costs of unplanned for or expensive medically necessary care.
Insurance coverage for breast reduction
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Preoperative Photos for Breast Reduction
The role of the primary care physician is to make a referral to a plastic surgeon. The plastic surgeon will most likely take photographs. However, not all insurance companies require photographs for pre-authorization. Insurance companies base their decision for authorization on multiple factors, such as:
1.The patient's symptoms
2.What non-operative therapies the patient has tried before (physical therapy, creams for rashes,etc.)
3.The amount of breast tissue that is estimated to be removed (based on a patient's height and weight)
Hope that helps and good luck!
Dr. Babak Dadvand
No photos for breast reduction evaluation
Depending on your insurance company, photographs may not be medically necessary for predetermination of breast reduction surgery. The next step is that your primary care doctor should make a referral to a board certified plastic surgeon who can then take measurements and photographs to determine the best method of breast reduction to meet your goals and expectations. I wish you a safe recovery and wonderful result!!
Paul S. Gill, M.D.
Gill Plastic Surgery
Houston Double Board Certified Plastic Surgeon
Photos for breast reduction
Most plastic surgeons take photos of everything and every patient and so it is surprising that yours did not take pre-operative photos. I would ask he/she to do so for documentation purposes even if the insurance company does not require them.
I hope that helps!
Breast reduction and photos
I always take my own photos. For approaval of breast reduction through insurance photos are used to evaluate the patient for precertification.
Photos before breast reduction
Many insurance companies do not require photos for the predetermination process for breast reduction, though a few still do. We find it is best to start the predetermination and then send what is asked for to support the request for surgery. The fewer people that have your photos the better.
Best of luck,
Photos prior to breast reduction
It is not uncommon to submit a letter and then wait for a request for photos if demanded by the insurance company.
Predetermination of benefits for breast reduction
Most plastic surgeons will do a predetermination of benefits before a breast reduction, where a letter and preoperative photographs are sent to your insurance company to get preapproval for surgery. Discuss this with your plastic surgeon at your initial consultation.
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.