Will Insurance Deny Coverage Because of What the Physical Therapist is Saying?

I went to the physical therapist and he told me that my neck, back, and should pain is due to poor posture! Nothing to do with my 40ddd breast. Will this allow my insurance to deny my any breast reduction surgery?" I am 5'3 160lbs

Doctor Answers 7

Breast reduction coverage

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Ask your Physical Therapist how he thinks the heavy breasts affect your posture. If he agrees that the heavy structure is a direct cause of bad posture (of course it is) he needs to include that in his summary. If he declines to do that, get a therapist that understands anatomy better.

Insurance coverage

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Every insurance plan has their own unique criteria on whether they will cover a breast reduction.  More and more, we are seeing plans where a breast reduction is not a covered benefit.  If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage.  Some set the amount in relation to your BMI (height and weight).  Others require extensive medical records documenting neck pain, back pain, and history of rashes.   The other alternative is to opt for a breast reduction as a self-pay option.   Start by visiting with a board certified plastic surgeon to learn more about your options.
Best wishes,

Dr. Basu
Houston, TX

Breast reduction surgery

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Your insurance company is unlikely to contact your physical therapist or even care what he or she has to say.  Your insurance company has specific criteria about breast reduction surgery usually requiring a minimum weight be removed from each breast.  They are however, somewhat hit or miss these days.  Have a plastic surgeon evaluate you, and determine if you are an appropriate candidate.

Insurance coverage for breast reduction

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It is usually your plastic surgeon who will be contacting your insurance company for prior authorization so I doubt that what the physical therapist says will affect the decision of your insurance company. You should see a plastic surgeon certified by the American Board of Plastic Surgery to evaluate you for breast reduction surgery. And good luck to you. Breast reduction surgery is one of the procedures that we do that makes the most difference in patient's lives.

Margaret Skiles, MD (retired)
Sacramento Plastic Surgeon

Breast reduction coverage

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First, view your insurance criteria online. Then, see a board certified plastic surgeon for evaluation. If he thinks you may be covered, you will be advised as to what forms of conservative medical management may be required.

Insurance Denying Coverage of Breast Reduction

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   Please make sure that your insurance covers breast reduction.  Then see a plastic surgeon to evaluate you.  The insurance company will try to deny you based upon a lot of things like weight, lack of enough tissue that should be removed, lack of symptoms, and lack of previous medical management.  Find a plastic surgeon who deals with these things on a regular basis.  I think there will be little if any weight placed upon the conclusions of a physical therapist.  Kenneth Hughes, MD Los Angeles, CA

Breast Reduction, Health insurance Coverage and Physical Therapy Evaluation?

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No, what your physical therapist is saying will not necessarily result in health insurance coverage denial for breast reduction surgery. After all, your disproportionately large breasts may be  contributing to your "poor posture".

 I would suggest that you seek consultation with well experienced board-certified plastic surgeons who may be able to guide you more precisely  and approach the health insurance company on your behalf.

 If one of the health insurance company's criteria  for coverage is physical therapy evaluation,  then you may just have to find a more “cooperative” physical therapist.

Best wishes.

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.