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My Dr. Ordered 800 CC/breast. My Insurance Said It Needs to Be 1800. Is That Risky?

I am heavy )5'5", 240 lbs. Could that be the reasoning behind the doubled request?

Doctor Answers 12

August 23rd, 2012

1800 sounds incorrect

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As the other surgeons have mentioned, in order for a breast reduction to be "medically necessary,"  it must meet certain criteria.  For the amount that is required by your height and weight, you are looking at somewhere between 900-950 gms per breast in order to meet at the 22nd percentile, which is what most insurance companies require.  1800gms might be your individualy carrier's criteria.  This is could also be both breasts, which is fairly close.  I would contact your insurance carrier's representative to discuss what your plan requires.

 

In addition most insurance companies will require more documentation and reasoning as to why it is medically necessary to reduce the size of your breasts than just a size issue.  You should discuss this further with a board certified plastic surgeon to understand what your insurance company requires.

Robert Kratschmer, MD
February 26th, 2012

Breast reduction?

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Without an exam, I could not assess an approximate weight that might be removed during a breast reduction.

Steven Wallach, MD
February 25th, 2012

Breast reduction

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Sounds like you are talking about breast reduction surgery, if so the amount to be removed is measured in grams not CCs. Each insurance company has its own criteria for height and weight and it looks like the 1800 grams are what they expect removed from both breasts in total and not from each breast. Hope that helps.

Antoine A. Hallak, MD, FACS
February 24th, 2012

Insurance Reduction Requirements Do Relate To Weight

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Almost all insurance companies do relate the amount of breast tissue removed to the patient's BSA (which tends to penalize women who are taller).  1800 grams of tissue does seem excessive if it is expected from one breast.  If this represents the total weight from both breasts, it probably is accurate.

John Whitt, MD (retired)
Louisville Plastic Surgeon

February 24th, 2012

You can calculate your requirements for breast reduction if you have internet access.

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Most insurance companies abide by the Schnur Scale.  Use an online calculator to determine your body surface area in meters squared and then go to the following web reference to determine the amount of breast tissue removal that is required for you. Then, call your insurance company to see if they use the Schnur Scale as well. I hope this helps.

Learn more: http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm

J. Jason Wendel, MD, FACS
February 23rd, 2012

Breast reduction

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1800 grams per breast is a very large reduction.  If the insurance company is calculating the minimum that it will allow for your height and weight, that is possible, although I have never seen an insurer express it in those terms.  They either approve or deny the reduction.  Plastic surgeons do not "order" a set number of grams per breast.  They estimate how much they intend to remove during the procedure and the insurer responds.  I agree with other posters that there is some miscommunication going on and that you need to speak to your doctor to clarify what is going on prior to proceeding with surgery.

Robert L. Kraft, MD, FACS
February 23rd, 2012

Breast Reduction

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If you are talking about breast reduction and grams (not ccs) to be removed, here are my thoughts.You need to get better communication with your surgeon. I bet he preauthorized 800gm per side and the insurance company wants 1800gm total. If so, you're close to covered. But few of us will remove breast tissue until we meet the insurance company's "requirements" because to do so may create a very deformed breast. So better get this cleared up.

Ronald V. DeMars, MD
February 23rd, 2012

1800 cc breast implants

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You miss-understood. There are no 1800 cc breast implants made in the USA. Larger sizes are made in Europe. Risk is not more if done by an expert in stages. You can't go from zero to 1800 cc in one step. It takes expanders first and a remove & replace later. You should be the one to decide the size you want to be, not the doctor. We help our patients make that decision with several different methods. Dr Foster

Lawrence Foster, MD (retired)
Sacramento Plastic Surgeon

February 23rd, 2012

Breast reduction requirements

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1800 seems a little high.  Check back with your plastic surgeon and bring your insurance information to verify the amount.

Learn more: http://marylandcosmeticsurgeryinc.com/breast-3/breast-augmentation/

Jeffrey E. Schreiber, MD, FACS
February 23rd, 2012

Breast reduction

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I think there is some miscommunication. In order to cover breast reduction surgery all insurance companies require medical record documentation of symptoms caused by large breasts like shoulder pain, skin rashes etc and a variable period of a trial of conservative therapy like support bras. Most also require that a specific amount of tissue related to body surface area be removed in order to meet medically necessary non-cosmetic criteria. In your case that would be between 800 and 820cc given your BSA of 2.14. If they are requiring the removal of such a large amount of tissue and you have a letter from them stating so you need to report that company to your state insurance regulatory agency and demand that the case be reviewed by an external reviewer.

Aside from that your BMI is 39.9 and your height weight ratio makes you morbidly obese. You should seriously consider weight loss or weight loss surgery before any body contouring surgery for health and safety reasons and to ensure a safe breast reduction surgery with less chance of complications and a more optimal result.

I hope you realize that this format of posting questions and receiving answers lacks the face to face direct communication required for you to make an informed decision regarding your surgery.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

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.