Reduction and insurance coverage

Question

My current bra size is 38H (UK)/ 38J (US). I recently had a consult. The surgeon stated my “magic number” is 700 (grams? CC’s?) per side. I stated I think I would like to be a C/D. He stated he feels confident he can get it from my right side, but not my left. He said he would like to submit for 675 on the right and 500 on the left. Since it’s such a difference does this typically present an issue for insurance? Does being so lopsided hurt or help my chances? I’m nervous to know possibilities.

Scott C. Lindsay, DO · Answer

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!

Ryan Rebowe, MD · Answer

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.

Elizabeth Kiwanuka, MD, PhD · Answer

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.

Irena Karanetz, MD · Answer

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

Camille Cash, MD · Answer

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.

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