What can I do if my insurance denies coverage for breast reduction?

Question

Hello! I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. But they denied my dr's request for "cosmetic" reasons, but its all health related for me. I have a referral to a phys. Therapist. Help, what else can i do?

Jed H. Horowitz, MD, FACS · Answer

I would recommend seeing a Board Certified Plastic Surgeon who is experienced in working with insurance companies for this particular procedure. It sounds like your primary care physician many not be able to submit the authorization without an opinion from a surgeon. Based on your symptoms you definitely qualify for a breast reduction. #BreastReduction #BoardCertifiedPlasticSurgeon #PlasticSurgery

Miguel Delgado, MD · Answer

It is hard to believe that your insurance denied your coverage due to it being cosmetic reasons with all the symptoms you have! You might want to see a Board Certified Plastic Surgeon that specializes in breast surgery to reapply for coverage, if you are denied again, ask your surgeon to appeal your case. Then a medical doctor will talk to your surgeon about your specific case. I have gotten several patient approved this way. Good luck!

Andres Taleisnik, MD · Answer

The saying "the squeaky wheel gets the grease" can apply in this situation as well. If you're persistent in your letters and calls to the insurer, they may reverse their decision and approve your surgery. Check Aetna's guidelines for breast reduction coverage on their website, then send a letter with all of the necessary information including your height/weight and symptoms. See if your plastic surgeon can give you an estimate of the weight of breast tissue he might remove from each side and include it with your letter. Your surgeon may not have submitted a good letter on your behalf. Follow up the letter with phone calls. You're the consumer, not the surgeon, so they care more about angering you than angering the surgeon. If your breasts truly look very large, you might also want to include photos from different angles (like those on this website). If nothing works, you can obtain price quotes from one or more surgeons and pay for the procedure. Financing options exist if needed.Good luck!Andres Taleisnik, M.D.

Jennifer Greer, MD · Answer

It isn't clear from your question- have you seen a plastic surgeon regarding breast reduction?  Your primary care physician would not be submitting paperwork to insurance for preapproval for surgery. If you have been denied coverage for breast reduction, there are two possible reasons:Your insurance company does not consider surgery medically necessary. If this is the case, your surgeon can file an appeal. If the appeal fails, your only option is to pay out of pocket for surgery.Your insurance company has breast reduction listed as an excluded procedure. This means it is not covered reglardless of whether it is medically necessary. Best of luck to you.

Joseph M. Perlman, MD · Answer

I reviewed insurance cases for many different health plans. The criteria for covering breast reduction is pretty strict. Many require you to be within 20% of your ideal weight, have one year documented history of back and shoulder pain where you visited an orthopedic surgeon or a chiropractor, or have a history of infections underneath your breasts that have been treated with antibiotics. Most women that I see don't meet the criteria for being  within 20% of your ideal weight. For example, if you are 5'6" tall, and you weighed more than 140 pounds, you wouldn't meet the criteria. You can file an  appeal with your insurance carrier and have any physician who treated you for any of the above conditions write a letter stating that it was medically necessary to have a breast reduction. Good luck

Tom J. Pousti, MD · Answer

I am sorry to hear about the difficult time you have had obtaining authorization. As you have found, it can be very frustrating dealing with insurance companies. I would suggest you write an appeal letter and have your physicians do the same. Look for the insurance companies' "criteria" and find as much support to meet these criteria. Be persistent.Best wishes.

Steven Holzman, MD · Answer

You seem to be a good candidate for reduction but you need to find out exactly why the carrier denied coverage.  Did you not meet the criteria?  Get a copy of the surgeon's letter and see if his wording on the letter worked against you.  Also, Aetna often denies patients that have failed 3 months of non-operative treatment such as PT, custom bras, use of medication, etc.  If you can identify the reason, go about getting a referral from your primary doctor to a therapist, or other specialist, or write for muscle relaxants, or get bras made, and then re-apply.  If denied, ask for a specialty specific (Plastic surgery obviously) review from Aetna.  Perhaps see a second plastic surgeon and use that info in your appeal.  Lastly, file a claim against Aetna with the State Board of Insurance claiming consumer fraud and dishonest trade practices for offering you insurance but not providing reasonable medical care.  Good luck.

John D. Smoot, MD · Answer

This becoming more and more of a problem with insurance companies and it comes down to the fact insurance companies no longer want to pay for this procedure. Your doctor can appeal the decision but if this fails you will have to pay for it.  You are a candidate for this procedure and I wish you luck.

Adam L. Basner, MD · Answer

Most insurance companies will give you an amount of breast tissue that needs to be removed for it to be considered medical and covered by insurance.  You can also provide documentation showing a history of issues that have not been resolved by other treatments... back pain, rashes, etc.You should have the option to "appeal" the insurance denial.

Josef Hadeed, MD, FACS · Answer

Thank you for your question.  From what you are describing, it sounds like you would be a candidate for a breast reduction.  However, it is difficult to make this assessment without the benefit of evaluating you in person.  There are several different criteria that insurance companies use when determining if a woman qualifies for a breast reduction under medically necessary reasons.  Usually, though, the request for authorization for the surgery should come from your plastic surgeon's office and not your primary care doctor.  A consultation with a board certified plastic surgeon can help you to understand what your options are.  Breast reduction surgery can be a very satisfying procedure for most women.  Best wishes.

What can I do if my insurance denies coverage for breast reduction?

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