Can a Breast reduction be approved through insurance without documentation of physical therapy?

Hello and thanks for your question.Whether you tried physical therapy probably won't be a major factor in obtaining authorization.Pre-authorization requirements significantly are different significantly when comparing different insurance companies. Please visit a good board certified plastic surgeon with good reputation. Typically photographs are needed to be taken and sent along with a letter indicating your symptoms.Best wishes,Dr Sajjadian

Preauthorization requirements really vary quite a bit between insurance companies.  I recommend you consult with a plastic surgeon who can start the authroization process for you which would require photos and documentation of your symptoms.  Whether you tried physical therapy probably won't be a major factor in obtaining authorization.

It will depend on your insurance company, most have several requirements and maybe not all need to be met, but you will have to check with your insurance company. Try to get whatever else you can to show what you have done to alleviate your symptoms, such as: letter from your general physician recommending a reduction for you, that you have tried taking analgesics, you have tried special bras. A letter from your physician and also from the Board Certified Plastic Surgeon may be enough, but again it will depend on your insurance company. Good luck!

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.

Hello,It's complex and difficult to get any procedure paid for by your insurance, especially if performed in an ambulatory surgery center, that skirts the lines between being cosmetic and medically necessary.Historically, the pendulum has swung back and forth between more or less willingness of insurance companies to cover this procedure.  Currently, it is difficult and payments are low, with almost no ambulatory surgery centers getting payments at all. If you want the best result possible, I would focus on the surgeon, not coverage. The time it takes to get all your ducks in a row for insurance coverage (it can take many months), you can find a great surgeon and get financed. Go visit a few ABPS certified/ASAPS member surgeons in your area. Best of luck!

Thank you for the question. 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, and the attached link, helps. Best wishes.

Hello and thank you for reaching out. Insurance coverage of a breast reduction can be determined by many moving parts and pieces, but evidence that a patient has undergone PT does not automatically disqualify a patient from coverage. Other factors such as BMI, past and present medical conditions and grams estimated to be removed from each breast will determine if the surgery is medically necessary. While the documents that you can provide stating you have had issues, PT, etc may help justify why the surgery is needed, not all hope is lost without it. Every insurance company is different, so please refer to your own for a better understanding. Best Wishes.

In general, the three criteria that the insurance companies look at are:
1) Symptoms must be attributable to large breasts
2) Conservative symptom management must have been tried and failed
3) A certain amount of tissue is planned to be removed
Patients with excessively large breasts (macromastia) typically
experience upper neck/back/shoulder pain as well as rashes under the
breasts. In patients who have existing cervical spine disease,
additional testing may be necessary to ensure that these symptoms are
due to macromastia rather than other causes.
Conservative management of upper neck/back/shoulder pain usually
consists of any non-operative treatment. This may include pain
medicines, accupuncture, exercise, going to a chiropractor, physical
therapy, etc. for a certain time frame, usually 3 months or so.
Conservative management of rashes under the breasts may include baby
powder, diaper rash ointment, or other medicated creams such as steroid
ointment.
Finally, insurance companies typically ask plastic surgeons to estimate
the amount of weight of breast tissue to be removed during the breast
reduction surgery. In order to make this estimation, your body surface
area is calculated based on your height and weight, and then this is
compared to a Schnur Scale which gives an estimation of the amount of
tissue necessary to be removed in order to provide symptom relief.
Although multiple research studies have failed to find associations
between the amount of tissue removed and symptom relief, this is
nevertheless a criteria used by insurance companies.Not specifically having documentation of physical therapy will not disqualify you from insurance coverage as long as there are other non-surgical treatments that have been tried.  In any event, your plastic surgeon will usually do a pre-certification to verify insurance coverage before surgery so you will know if it's approved.

There are several things that can be done to try and get your breast reduction approved by your insurance. One of them is to submit photos to show the position of the nipples as well as the shoulder grooves or any dermatologic problems.

Insurance coverage for breast reduction is a tricky thing sometimes and totally dependent on your specific contract. Physical therapy is a total waste of time for patients whose pain is from large breasts but insurance companies frequently require it just to stall and put up roadblocks hoping the patient will give up.