50 years old, 5'8" and 210lbs. Currently I am a 42DD. Last year I weighed 240, even with wight loss breast size has not decreased. I've also been diagnosed with hypothyroidism - hence losing additional weight has been challenging and I seem stuck. Insurance denied request of 500 gram reduction stating the Schnur Scale states 750 would need to be removed. I have deep groves in my shoulders, pain, cardio is challenging etc. My pant size is a 14, my top size is an 18. Do I have any recourse?
Am I a Candidate for Having Insurance Cover my Breast Reduction?
Doctor Answers 6
Insurance coverage for breast reduction.
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.
Am I a candidate for having insurance cover my breast reduction?
It would be in your best interest to have a mammogram prior to the procedure for screening prior to this procedure, as the architecture imaging of your breast will slightly change afterwards. Well known data exists that having a breast reduction will in fact lower your chance for developing breast cancer, simply because the amount of tissue will be less.
Consult with a board-certified plastic surgeon who will discuss the procedure with you, examine, and assist you in determining if this is the right procedure for you. Voice your complaints - your insurance will likely require a detailed description of your history and complaints as well as photo and an estimate of how much tissue will be removed. You should give a description of the therapies that you have done to ameliorate your complaints thus far. Any other notes from other physicians is helpful. It would also behoove you to discuss your issues yourself with your insurance carrier. Hope that this helps! Best wishes and good luck!
The more documentation that you can provide to demonstarte medical necessity the better. Many patients will have neck and back pain related to large breasts. If you have seen other physicians or health care providers for these symptoms providing this information may improve your chances with an appeal. Chronic rashes underneath the breasts may also occur. Photodocumentation of this problem as well as documentation of treatment of this problem may be helpful for patients with rashes. Your insurance plan may have specific criteria that are used to approve breast reduction surgery. Check your plan to see if you meet these criteria. Good Luck!
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Problems obtaining insurance authorization for breast reduction
Did a plastic surgeon assess you and estimate that 500 grams would be removed per side? If he/she did and submitted this information to the insurance company only to be denied coverage for a breast reduction, you do have an option to have this appealed to someone higher up in the company. If you have clear cut evidence and documentation of physical issues and problems related to your large breast size, you may be able to have the initial rejection reversed. I have had success with many of my patients with this approach - but not all. Some insurance companies are very rigid with (some of) their criteria which if you do not meet - there is no recourse.
Your other option, though not as desirable, is to pay for a breast reduction out of pocket.
Getting Insurance to Cover Breast Reduction
Each insurance company has it own guidelines. Most require 500 grams of tissue to be removed from each breast. Since you have been denied coverage, there is one more thing you can try. Most insurance companies allow you to appeal their decision, in which case a doctor would contact your surgeon to discuss your case. I have had more than one reversal in this situation, so it is definitely worth a try! Good luck.
Breast reduction insurance coverage?
Based on your description you may be a good candidate for breast reduction surgery; as you know it may be in your best interest to drop weight first.
The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. 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.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're saying a well-trained/experienced board-certified plastic surgeon.