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Insurance Denied Surgery After Breast Reduction Surgery Completed?

My PS got my breast reduction surgery approved based on an amount of 360 grams of tissue being removed from each breast. After the surgery, he only took 200 grams out of each breast fro a total of 400 grams. My insurance is not denying my claim. I did not do a pre-approval, but they did give a pre determination of approval. How could he have been so "off" on the amount taken out?

Doctor Answers 6

April 11th, 2016

Breast Reduction

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Breast Reduction is a complicated procedure that is best done by those with the most training and experience. It is very difficult to determine the resultant cup size and shape based solely on the number of grams that are removed from your breast to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast reduction and lift surgeries, including different approaches, techniques and even fat transfer and implant choices if you are lacking superior breast fullness.
This is because several measurements—not to mention breast characteristics such as density—are needed to determine how much and where to remove breast tissue to meet your goals. Without knowing your existing breast shape, dimensions, and the density of your breast tissue, it would be difficult to make this determination. For example, the same volume of breast tissue will weigh different amounts (measured in ounces or grams) in different people depending on its density. The existing base width of your breast and what you will ultimately want to look like will determine, in many cases, the maximal volume and weight that will need to be removed for the best result.

Please click on the link below for more information!

Learn more: http://drnichter.com/optimal-breast-reduction/

Larry S. Nichter, MD, MS, FACS
February 20th, 2013

Problems with breast reduction insurance coverage

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This is one reason why I refuse to do breast reduction surgery.  I work for the patient to give them the absolutely best result.  I will not be dictated to by an insurance company about how much breast tissue is appropriate to remove.  It is only an estimate.   The problem is that as the plastic surgeon you are responsible for the surgical outcome.  If too much breast tissue is remove in some cases there can be wound healing problems, excessive scarring and loss of the nipple and areola.  The insurance company is not going to take responsibility for any of the problems as you mindlessly remove a predetermined and completely arbitrary volume of breast tissue.  The denial of your claim should be vigorously fought.  The insurance company has placed your plastic surgeon in a position where is his no longer your advocate.  Welcome to the future of medicine.  

Jeffrey Zwiren, MD
February 20th, 2013

Insurance Company Denied Coverage after Breast Reduction?

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I'm sorry to hear about the problem you are experiencing after breast reduction surgery. As you can imagine, online consultants will not be able to help you when it comes to your question about your plastic surgeon's “miscalculation”.

 At this point, I would suggest that you continue to use your plastic surgeon as a resource;  hopefully you both can continue to work with the insurance company to “appeal” coverage for the procedure.

 Otherwise, unfortunately there will be no recourse as to the financial arrangements;  usually the patient is responsible for payment to the “parties” involved.  Hopefully arrangements can be made for “cash discounted” payments.

On the brighter side,  hopefully you will be very pleased with the long-term outcome ( functionally and aesthetically) with the breast reduction procedure performed.

 Best wishes.

Learn more: http://www.poustiplasticsurgery.com/Procedures/Procedure_breastReduction.htm

Tom J. Pousti, MD, FACS
February 20th, 2013

Amount of tissue removed

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Insurance companies have charts to tell them how much tissue should be removed in order for them to cover it as a breast reduction rather than a breast lift with a slight reduction (which they consider cosmetic).  Insurance companies also realize that doctors can only estimate how much tissue they will take out pre-operatively.  Obviously, the only way to truly tell how much tissue will be removed is to weigh it after it is removed.  With that in mind, most insurance companies allow for a little bit of leeway as far as how much tissue they require.  I agree with you that 200 grams is certainly a far cry from 400 grams and I don't know how your doctor was so far off in his estimate.  You would have to ask him that question.  Frankly, I am surprised that they approved an amount of only 360 grams.  Usually they want a lot more than that.  Still, you said that they did NOT deny your claim so it sounds like it all worked out for you in the end.

Edwin C. Pound, III, MD
February 19th, 2013

Post-op Insurance denial of Breast reduction

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Sorry to hear of your predicament.  Insurance companies are usually very strict in specifying the resection weight (gm of tissue)/side as well as ensuring that your BMI (Body Mass Index) is "normal".  Insurance doesn't want to sponsor "cosmetic surgery" and a mastopexy is a small breast reduction (i.e. 200gm vs 360gm).  Did you and your PS agree on a) your desired cup size & b) whether (s)/he felt the predetermined weight was appropriate?  Assuming you both agreed that breast reduction was indicated to relieve your symptoms and that your targeted "cup" size could be maintained, you should discuss your concerns with him/her and ask for a letter to appeal the insurance company's denial.  Good luck.

Lavinia K. Chong, MD

Lavinia K. Chong, MD
Orange County Plastic Surgeon
4.8 out of 5 stars 58 reviews

February 19th, 2013

Insurance company not paying for breast reduction

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I am sorry to hear the insurance company does not want to cover the cost of your surgery but let me explain some facts about insurance coverage and breast reduction. Breast reductions should be medically necessary to be approved for surgery. It is always recommended to get the preapproval which should include the estimated minimum amount of tissue to be removed. I am surprised that they approved 360 as the usual minimum is 500 grams.  Any reduction less than the estimated amount could be open to dispute. You have to discuss the circumstances of the under resection with your plastic surgeon. Remember that our main concern is your ultimate result and I hope you are happy with yours. Sometimes we have to air on the side of your over all satisfaction with the result at the risk of the insurance denial of payment. Again, I am surprised the approved 360 gm and in most cases a reduction of 200 gm will be considered not medically necessary. Hope this helps.

Humberto Palladino, MD, FACS

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.