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

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.

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.

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

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.

Hello, and thank you for your question.  I'm not sure that I understand your question.  I give it a try.

It sounds as though you're considering a breast reduction.  If I'm mistaken you can pretty much ignore the rest of this answer.

If a breast reduction is to be covered under insurance which is becoming increasingly more difficult we generally submit photographs of the patient, the indications for the surgery, and an estimate of how much tissue will be removed to the insurance carrier.  With this information the insurance carrier may approve or disapprove under the your policy coverage for breast reduction surgery.

It sounds and your question is though your doctor Estimated about 800 g per breast, but your insurance carrier may not be willing to cover your surgery unless he takes off 1800 g? 1800 g is a huge amount of breast tissue so again I apologize if I'm not understanding the question. For example Blue Cross generally requires about 600 g per side.

You may want to post this one again with a little bit more detail.

 

Best wishes.

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.

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

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.

Thank you for the question.

Congratulations on your decision to proceed with breast reduction surgery;  this operation tends to be one of the most patient pleasing operations we perform.

You will find that every insurance company has a different  “criteria” they expect to be met (weight of breast tissue removed from each side)  in order to have the breast reduction procedure approved/covered. It will be best for you to check with your plastic surgeon whether he/she feels that  your insurance company's requirements are reasonable  and whether you will have a nice result with the required amount of breast tissue removed.

In my experience, 1800  grams is extreme;  I wonder if there has been some miscommunication and the insurance company has an 800 g requirement. Again, best to check with your plastic surgeon and/or insurance company.

Best wishes.

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.