What is the best way to get my insurance to cover my breast reduction? Should I go straight to a surgeon or to my primary Doctor

Question

Would it be easier for me to get my insurance to cover this if I went through my regular physician or if I went straight to a surgeon and have them do the paperwork? I have back pains and posture problems? I have the scars and indents in my shoulders from my bra and dark spots under my breast.

Richard H. Tholen, MD, FACS · Answer

Your primary physician will not be able to provide information about breast reduction surgery, although s/he will need to complete a pre-operative physical examination. Insurance prior-authorization is something your chosen plastic surgeon would do, and in addition to the subjective criteria of back and neck pain, shoulder grooving from bra straps, inframammary intertrigo (rashes), and sometimes brachial plexus compression form bra straps on the nerves in your shoulders, objective criteria (height and weight--BMI) are used to determine the exact minimum of breast tissue that must be removed per beast in order to qualify for reimbursement. What this means is that the larger you are for a given height, the more breast tissue that must be removed, with minimums of 400g per breast (usually). This is a minimum of nearly a pound of tissue per breast, and more if you are overweight. Pains and posture are insufficient for coverage, since every woman with large breasts can claim some degree of pain and posture problem, and every insurer can claim that if you lost weight, your breasts would reduce and you symptoms would diminish as well. So you see the problem here.You should start with a plastic surgeon who is ABPS-certified, a member of ASAPS, and with lots of breast experience. S/he will know the formula, and can show you a breast implant whose volume is the calculated amount that must be removed per breast. Then, you can determine if what remains is satisfactory for your body proportions. You always have the option to pay cash and then have full freedom to have your chosen surgeon remove only skin (breast lift), a small amount of breast skin and tissue ("cosmetic reduction"), or anything of your choosing, since insurance mandates are not in play.But if you want insurance to cover surgery, then you must follow their subjective AND objective criteria. Start with plastic surgical consultations. Best wishes! Dr. Tholen

Carlin Vickery, MD (retired) · Answer

Thank you for your question.Insurance coverage for breast reduction varies depending on your carrier and your plan.  As a rule it requires documentation that you have ongoing symptoms of neck, shoulder and back pain that have failed conservative therapy.  Conservative therapy can be physical therapy, chiropractor treatment, use of anit-inflammatories and use of supportive bras.  The companies want to see documentation of this therapy so you will need at least one letter from a health care professional who has treated you.  Each carrier is different.  Additionally, plans will want to review your pictures, your plastic surgeons notes especially the amount of estimated tissue to be removed.  Some carriers have requirements about your body mass index.   In most instances, you will need to see both your primary care physician as well as your plastic surgeon. You could start with a call to your insurance company to obtain a list of their requirements.  It is most efficient to collect your documentation with letters before you see your operating surgeon.

What is the best way to get my insurance to cover my breast reduction? Should I go straight to a surgeon or to my primary Doctor

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What is the best way to get my insurance to cover my breast reduction? Should I go straight to a surgeon or to my primary Doctor

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Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.