What Happens if You Estimate More Tissue Removal Than You Can Take out in Surgery?

Hello. I am 5'10", 195lbs and currently measuring 34" rib cage and 42-43" at the fullest part of my bust (somewhere DDD-F?In the last 18 months or so I have lost almost 70 pounds. I do have excess tissue and volume. At consult, surgeon told the nurse to submit to insurance for 600 grams. Ins. sent a pre-authorization approval. My question is - if during surgery, the surgeon finds that he cannot remove 600 grams - what happens to the insurance approval? Is it revoked and I am stuck w/bill?

Doctor Answers 7

Breast tissue weight requirements for breast reduction surgery

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Most insurance companies use an arbitrary amount of breast tissue that needs to be removed to differentiate between a breast lift and a breast reduction.  There was a time when If the patient had symptoms related to large breasts then insurance coverage was never questioned.  In 25 years of practice I have never had an insurance company retroactively deny coverage.  We try to give a fair estimate of the amount of breast tissue that will be removed during surgery but this is only an estimate and does not take into account individual anatomy and possible restriction of the blood supply.  As a plastic surgeon I work for the patient and not the insurance company.  If during a surgical procedure I felt that it was unsafe and not in the patients best interest to remove enough breast tissue to meet these so called weight requirements then I would do just that.  To do otherwise would be below the standard of care.  

Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Grams removed low - will insurance still cover?

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Insurance companies have tables indicating the grams that have to be removed for you height, weight, and BMI. These are different for each insurerer. As long as the resected weight is adequate according to that table, they will still cover the procedure. If your doctor is a provider, he may have access to that table, and some are published on line. You can also call and ask for it, and they will often give it to you. A lot of the time, however, as surgeons we don't know. The resected grams on request are just a guess. All you can do, if denied because of low weight after surgery, is to submit an appeal. These are occasionally successful, but insurance companies are getting less and less likely to pay as time goes on, requirements are stricter, and payments are lower.

Lisa Cassileth, MD, FACS
Beverly Hills Plastic Surgeon
4.7 out of 5 stars 16 reviews

Gram weight removal in breast reduction

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If you are still a DDD-F cup, I do not think your doctor will have difficulty reaching the 600 gram threshold. However, you raise a great question. Many insurance companies now require that we submit the post op pathology report which lists the gram weights. They have become wise to borderline cases and, especially when the patient begs to be a big C or small D cup and the plastic surgeon obliges, it can create a situation in which they will retroactively deny the case, sticking you with the full surgery, anesthesia and facility fee. In NY, GHI in particular is playing this game. I bring a scale into the OR and weigh the tissue during the operation and make it clear to patients that, if they want insurance to cover the procedure, the minimum gram weight must be removed. The alternative is paying for the surgery and not seeking insurance coverage. I think it is incumbent on us, as experienced plastic surgeons, to be extremely forthright about the insurance requirements, the expected result and whether the requirements and the patient's goals are aligned.

Breast Reduction and Insurance

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Coverage will depend on your insurance's criteria. Most require a minimum of 500 grams to be removed from each breast. For most women that would be DD or larger. If it is less than that, they may not cover it. However if you are DDD or larger you should have no problem. But you should discuss this with your surgeon so you know where you stand. Good luck.

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 81 reviews

What Happens if You Estimate More Tissue Removal Than You Can Take out in Surgery?

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Short answer to your question is: yes, if the required amount of breast tissue is not removed, the insurance company can deny payment and you will be responsible for covering  expenses of all parties involved. Hope this helps.

Amount of breast tissue removed and insurance payment

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Thank you for the question. It is really hard to tell what the insurance company will do. They may pay the claim and sometimes they will deny it. Therefore, it is the experience of the surgeon that you and the insurance company are relying on when the procedure is approved. Good luck.

Moneer Jaibaji, MD
San Diego Plastic Surgeon

Insurance and breast reductions

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Insurance companies often want an estimate of the amount of tissue to be removed before giving approval for the surgery. Often times I under estimate the number for my personal comfort to obtain at least the amount that they require.  I have never had one denied in retrospect after initial approval..

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

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.