How long is the breast reduction process and would I benefit?

If
you experience any neck, back, or shoulder pain, bra strap grooves, skin
irritation or infection, poor posture, decreased activity or other functional
problems that are related to large breasts then breast reduction surgery may be
covered under your insurance. Insurance coverage depends upon specific terms of each
policy, and individual patient factors/symptoms.More
frequently, however, breast reduction is written as an exclusion in many
insurance policies.



Patients seeking insurance coverage for breast reduction surgery
(performed for symptomatic breast enlargement) must have their plastic surgeon
obtain written pre-authorization of medical necessity from the insurance
company. Insurance policies vary
tremendously in their extents of coverage, requirements, documentation, and
exclusions. Most insurance policies have specific requirements for minimum
amounts of breast tissue that need to be removed. Some insurance policies require
overweight women to lose weight prior to surgery. Still other policies may
require an orthopedic evaluation of back pain, or a trial of physical therapy
and anti-inflammatory medication prior to authorizing surgery. And, many insurance
policies specifically exclude breast
reduction surgery, even if it may be medically indicated. Some of these
requirements may seem unfair or not make sense, but if these specific
provisions are written into a patient’s insurance policy they must be followed
if insurance coverage is expected. As
all policies differ, it is important to check with your insurance company for
the specific documentation you are required to file when seeking a medical
necessity determination.



Many
insurance companies are now requiring that some or all of the following
criteria, or other similar criteria, be met in order to be considered allowable
for coverage for breast reduction.



1). The
patient has significant symptoms, documented in their medical records, which
interfere with activities of daily living, including:

pain
in the upper back, neck, and shoulders which is of long-standing duration and
increasing in intensity, and/or

Persistent,
non-seasonal submammary skin rash/inflammation/irritation (intertrigo) which is
unresponsive to local hygiene and topical anti-infective therapy, and/or

Ulnar nerve paresthesias resulting
in pain and/or numbness in the arms and/or hands.

2). The
physical exam must document:

Significant
shoulder grooving or skin ulceration, and

Obvious
breast hypertrophy, and

Sternal
notch-to-nipple distance > 28cm for women > 5’2” tall, or >
25cm for women < 5’2” tall, and

Physical exam findings consistent
with symptoms related to mammary hypertrophy.

3). There
must be a failure of (sometimes documentation is required) a comprehensive
conservative treatment measure, including:

A
minimum of 6 weeks of physical therapy for the back, neck, and/or shoulder pain
including a maintenance home exercise program, and

Appropriate
support bra with weight distributing straps, and

Anti-inflammatory
medication, unless contraindicated, and

Symptomatic
measures, including application of heat and cold, and

Appropriate local hygiene and
topical medication for intertrigo.

4). The documented
Body Mass Index (BMI) must be < 30, which is below the level considered
“obese” according to the guidelines of the National Institutes of Health (NIH)
– National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obese Adults.



Following
your evaluation, your surgeon would estimate how much tissue needs to be
removed; and usually this is discussed during the consultation. Your plastic
surgeon would then submit a letter to your insurance company documenting the
history and exam findings and request prior authorization for breast reduction
surgery. The entire process may take 4-8 weeks before an answer is obtained
from the insurance company. If breast reduction surgery is approved –great; I
am sure you will feel much better following your surgery. If not, then there is
usually a method by which patients can appeal the decision.



Breast
reduction surgery is considered “cosmetic” (patients pay out of pocket) for
those individuals who are asymptomatic or do not meet the criteria for medical
necessity set forth by their insurance company.



The
satisfaction rate following breast reduction surgery, for women who suffer from
symptomatic breast enlargement, is very high. Women experience improvement/resolution
of chronic aches and pains, and usually have increase freedom of movement and
activity. Many say, “I wish I would have done this years ago.”



It sounds
as if an evaluation for reduction surgery is certainly appropriate for what you
describe about yourself. I would recommend you see a plastic surgeon to discuss
your options and see if you qualify under your insurance plan.



I hope this
helps. Best wishes. Ken Dembny

Each insurance company is a bit different and some will approve it by phone, some require a letter and photos, and some want medical records reporting conservative management failure.