Reduction and insurance coverage

Thanks for your question! This is all dependent on your insurance company. If he needs 700 grams per side and can't get it, then they may deny the claim. You can always seek a second opinion if you feel it's necessary. Good luck!

With the amount of tissue that you have per breast, getting this covered under insurance should not be an issue. Typically insurance companies will look for a specific amount of tissue (typically 500g) per breast to qualify for a formal breast reduction. Other times, it can be 1000g total. Either way, it sounds as if you have plenty of tissue to qualify. Asymmetry neither hurts nor helps your chances of getting is covered, but is very common.

When it comes to insurance coverage for breast reduction surgery, each case can be unique, and several factors are taken into account. These factors typically include the amount of tissue to be removed, the symptoms you're experiencing (such as back pain, shoulder pain, etc.), and the overall health benefits of the surgery.
The "magic number" your surgeon referred to likely indicates the amount of tissue to be removed. The difference in tissue removal between the right and left side might initially seem concerning, but it's not uncommon for surgeons to address asymmetry during a breast reduction. Insurance companies are generally more concerned with whether the surgery is medically necessary rather than the exact amount of tissue being removed from each side.
Here are a few points to consider:
Medical Necessity: Insurance companies typically require documentation showing that the surgery is medically necessary. This includes evidence of symptoms that significantly affect your daily life and have not been resolved through other treatments.
Documentation: Detailed notes from your consultations, including the surgeon's recommendations and reasons for the tissue removal amounts, will be crucial. The surgeon's explanation of the asymmetry and its impact on your health can also support your case.
Insurance Policy: Each insurance policy has its criteria and guidelines for approving breast reduction surgery. It's essential to review your specific policy or speak directly with your insurance provider to understand their requirements.
Appeal Process: If the initial request is denied, there is often an appeal process. Additional documentation and a letter of medical necessity from your surgeon can help during this phase.
Consult with Your Surgeon: Discuss your concerns with your surgeon. They have experience dealing with insurance companies and can provide insights or adjustments to their approach to increase the likelihood of approval.
It's natural to feel nervous, but with thorough documentation and clear communication with your healthcare provider and insurance company, you can navigate this process more effectively.

Hi,

Thank you for the question.

Based on what you are describing, it does sound that you have large/heavy breasts causing physical symptoms, and breast reduction may be an option for you. However, it is difficult to tell without seeing the photos and/or in person consultation.

Schnur Sliding Scale is a scale used by many insurance companies as a guideline for how much breast tissue should be removed in order to improve your physical symptoms. In addition, most insurances in order to approve the surgery, will require for 2-3 letters of medical necessity (from your chiropractor, primary doctor, OBGYN, Dermatologist, etc) demonstrating that your physical symptoms due to large breasts are not improving with conservative management.

The goal of breast reduction surgery it to make the breasts smaller and lifted, but also proportionate with the rest of your body. It is reasonable to to expect full C/small D cup breast size after the breast reduction surgery.

I suggest that you seek an in person consultation with a Board-Certified Plastic Surgeon specializing in Breast Reduction surgeries to further discuss your options, specific techniques, concerns and expectations. Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.

I hope this helps.
Best regards, Dr. Karanetz

Dr. Irena Karanetz
Breast Fellowship-Trained
Board Certified Plastic Surgeon

At size 38, each 200 grams removed corresponds to 1 cup size change. Insurance may require large numbers to be removed which may result in you being too small. The technique I recommend is The Bellesoma Method. This will reduce and reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. The weight of the breast is transferred to the underlying pectoralis major muscle resulting in pain relief without excessive reduction. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained. This technique is not covered by insurance companies.

Best Wishes,

Gary Horndeski, M.D.

Some insurance companies will require the amount from both breasts. The usual amount is 500 grams per breast for women with normal weight. If you are overweight, the amount increases. Many companies will not budge of their numbers. You can either lose weight or go smaller in size so more can be removed.

From your description it sounds like you are a good candidate for a breast reduction. Your surgeon will submit her/his findings and rationale to the insurance company for consideration. It is still a significant reduction. They may come back and ask for clarification or further information. There is no accurate way to predict if they will provide approval.

I suggest you contact your medical insurance company and ask them what their criteria is for authorizing breast reduction surgery.
That way you’ll know what the actual rules of engagement are.
The decision is always objective. Authorization is based on first having a diagnosis that can only be treated with this procedure.
That generally means neck and back pain That cannot be managed with medical treatment or skin rashes that again cannot be managed with medical treatments.
Insurance company will have number or a formula of a certain amount of tissue that the surgeon needs to estimate that they will remove the guard
The shape of your breast are having breast asymmetry that’s nothing to do with getting this procedure authorized.
Have your provider request authorization and if they deny the procedure, then they should tell you why.
Recognize that insurance reimbursement is usually only a tiny fraction of what most plastic surgeons charge for this procedure
Surgeons cannot charge their patience if they accept medical insurance reimbursement.
The difference in insurance reimbursement compared to what fees would be dramatic it’s never a bad idea to have multiple consultations.
Consider working with the plastic surgeons in your community could do most of the breast cancer reconstruction.
These surgeons work with medical insurance on a regular basis and are usually very good at breast surgery.
Breast cancer and reconstruction often involves symmetry surgery, which often includes breast reduction surgery.
Some plastic surgeons are motivated to not take insurance reimbursement because the payment is very low.
Make sure from the very beginning you’re working with a plastic surgeon who is upfront about your willingness to accept insurance reimbursement.
Best,
Mats Hagstrom MD