Breast Reduction Insurance Criteria Newport Beach, Orange County
Breast Reduction Insurance Criteria
Does Insurance Cover my Breast Reduction Surgery?
Breast Reduction Insurance Coverage
Breast reduction involves the removal of glandular tissue, fat, and skin from the breasts. Most insurance companies consider approval for coverage of breast reduction on an individual, case-by-case basis, when needed to alleviate or correct medical problems caused by excessive breast tissue. Women presenting with various forms of breast overgrowth (for example, macromastia or gigantomastia) accompanied by persistent clinical signs and symptoms that adversely affect health are the suitable candidates for breast reduction insurance approval.
If you are considering breast reduction surgery, first read your insurance policy. In most cases, insurers require the plastic surgeon to write a letter describing your symptoms and physical findings, estimating the breast weight to be removed, and requesting insurance coverage for breast reduction. This should be done prior to scheduling surgery because the insurer may not be obligated to pay if breast reduction surgery was not pre-authorized. If your insurer denies coverage by labeling breast reduction surgery as cosmetic, your doctor must educate the insurer about symptomatic macromastia and explain the difference between breast reduction and its cosmetic cousin, breast lift.
Typically insurance companies consider breast reduction surgery medically necessary for non-cosmetic indications. Depending on your policy most or all of the following breast reduction insurance criteria must be met:
1.) Persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:
Pain in upper back
Pain in neck
Pain in shoulders
Painful kyphosis (back bone disorder) documented by X-rays
Pain / discomfort / ulceration from bra straps cutting into shoulders
2.) Photographic documentation that confirms the overly large breasts
3.) Evaluation by a physician who has determined that all of the following criteria are met:
There is a reasonable likelihood that the symptoms are primarily due to macromastia
Breast reduction is likely to result in improvement of the chronic pain
The surgeon estimates that at least 350 grams or more of breast tissue will be removed from each breast.
Persistent pain, as documented by the physician, despite a 3-month trial of therapeutic measures such as:
Supportive devices (e.g., proper bra support, wide bra straps)
Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the inframammary fold in and of themselves are not considered medically necessary indications for breast reduction by most insurance companies. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g. good skin hygiene, adequate nutrition) for a period of six months or longer, but also must satisfy the criteria stated above.
Up-to-date insurers should be familiar with the current standard of care for treating macromastia, and should approve coverage based on reasonable criteria and documentation of medical necessity. Unfortunately, too many insurance companies do not yet consider the last two decades of medical literature proving the effectiveness of breast reduction surgery in relieving symptoms of macromastia regardless of a woman’s body weight. If you get a denial on your breast reduction insurance coverage and feel that breast reduction is necessary for your health and well-being, you are legally entitled to appeal. The appeals process should be described in the denial letter. In most cases, multiple levels of appeal are available, and you should take advantage of them. Letters from a family doctor, orthopedist, physical therapist, chiropractor, or massage therapist can help support an appeal. You should write your own letter describing your symptoms and how they have limited your life (focus on your physical problems rather than your difficulty finding a bathing suit). Ask your doctor to submit a personal letter, supporting letters, up-to-date scientific information about the standard of care for treating symptomatic macromastia and a list of medical literature references on breast reduction with the appeal.
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