38 J but dr said my whole breast is only 1000g?

Question

I have aetna insurance which has very strict rules of what needs to be removed to be approved. I am currently 5'7 and 185lbs and I I got a consultation and the prior auth was denied due to not removing enough. I needed about 1000 g per breast removed and the dr said that would be my entire breast...it's not adding up to me, according to "a bra that fits" I am a 38J (US) and that size fits, maybe 1 size down...

Jeremy S. Nikfarjam, MD · Answer

Hi Stone,
Insurance companies are difficult to work with in this regard! Their scales for medical necessity are a bit arbitrary. Many plastic surgeons don't work with insurance on a regular basis and can easily get tripped up in the red tape. They create so many hoops to jump through that cases will fall through the cracks. 
It could be true that 1000g is the recommended amount to be removed based on your insurance company's scale. It could also be true that 1000g is too much to remove while leaving you with an aesthetically pleasing outcome. However, I always tell my patients that regardless of what insurance says, it is my duty as a physician to do what's in my patient's best interest. My clinical decisions are separate from insurance company's guidelines. 
I wish you the best of luck in your search for treatment!
- Dr. Nik

Finny George, MD · Answer

Hi, thank you for sharing your question. There is no accurate way to measure your current breast weight. Therefore, adhering to the requirements from an insurance company may leave some patients smaller than they anticipated. Photos or an in person physical exam are always helpful.

Daniel Barrett, MD · Answer

Dear stonel1994,
it is hard to tell for sure without an examination. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Dustin Christiansen, MD · Answer

In theory breast volume and cup size should correlate exactly. However, because of different body shapes and inconsistent cup sizing from bra manufacturers they don’t always match the way we think they should. I have seen countless patients who wear bras with very large cup sizes, but their actual breast size does not reflect what one would expect from that cup size. Your situation is not all that unusual, and if your surgeon is experienced with breast reduction, their estimate of volume is probably fairly accurate.

Farbod Esmailian, MD · Answer

Insurances have different requirements on what has to be present for them to approve a procedure. In certain cases it is wise to go out of pocket and pay for the procedure rather than allow the insurance to dictate how big of a reduction is required for insurance to cover.

Hope that helps.

Hope that helps.

Connie Hiers, MD, FACS · Answer

Your doctor knows how much volume he needs to keep the blood flow to your nipples and keep them alive. Since you are overweight, the amount of breast tissue that is required to be removed does go up. Try losing about 40 pounds and then see what is required by Aetna if you want insurance to cover your reduction.  Most companies want about 500 grams per breasts when you are near your ideal weight. For you, that weight is around 135-145 pounds, with 135 pounds at "ideal".

Camille Cash, MD · Answer

Photos or exam is needed for a specific recommendations.  Breast reduction will decrease the volume and weight of the breasts as well as lift them.  This often provides relief for the patient from concerns such as neck and back pain and rashes under the breasts.  I encourage you to visit with a board certified plastic surgeon near you to determine if you are a good candidate and if the amount required to be removed by your insurance carrier is a realistic possibility for you.

Lisa L. Jewell, MD · Answer

According to the information you provided, your body surface area is 2.03 m2 (depending on which formula is used) and according to the BC/BS Schnur scale that would require your provider to remove a little less than 700 grams of tissue from each breast. That would roughly be about 2-3 cup sizes down. So starting from a J cup you would likely go down to a G cup. Please keep in mind that these are all just estimates. However, if your surgeon estimates that you are starting with only 1000grams, that would leave you with only an A cup or less AND might endanger the blood supply to your nipple. Remember that bra sizes are not standardized, so a "J" cup in one manufacturer may be a "DDD" cup or a "D" cup in another. Additionally, your surgeon may remove MORE than the estimate to give you the size you desire, but if he/she removes significantly less than the estimate, your insurer may not authorize the payment to the surgeon (after the fact) leaving you ultimately responsible. He/She must also leave enough tissue behind to keep your nipple and areola alive (unless you choose to have a free nipple graft) so the removal vs what is left behind is a balancing act when insurance companies are involved. If you have the option to pay out of pocket for your surgery, this may be the best option for you. Ask your surgeon if there are financing options available.

Michael Ablavsky, MD · Answer

Insurance policies often differ when it comes to breast reduction authorization but most look for a functional deficit caused by large breasts (rashes under breast, bra strap grooves, and possibly upper back pain). The Schnur sliding scale is a chart that will determine how much volume needs to be removed for coverage - volume removed is based on BSA (height and weight metric).  Bra sizes are often subjective and can very from one company to another.

Shana Kalaria, MD · Answer

The typical breast reduction is around 500g or half of what your insurance requires. It is possible to remove 1000g, but what your surgeon is trying to say is that that would leave you with a completely flat breast which would not be aesthetically pleasing to you.

38 J but dr said my whole breast is only 1000g?

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