One of the most unexpected “roadblocks” for patients considering surgery is their health insurance. Many patients are well into the process of planning for surgery – researching surgeons, enduring (sometimes multiple) consultations and examinations – before discovering that their insurance policy will not cover the procedure they require. This is especially true for women desiring breast reduction.
In many cases, the size of a woman’s breasts can significantly hinder her ability to work, exercise, even to care for her family. The weight of excessively large breasts can cause pain in a number of seemingly unrelated areas. After years of wearing “industrial-style” support bras, grooves begin to develop across the upper shoulders, putting a strain on the muscles, often resulting in headaches and neck pain. The delicate skin under the breasts can become inflamed or infected. Chronic lower back pain is another common complaint as women attempt to shift their weight to compensate, affecting their posture. Many women seek relief through chiropractic treatments, acupuncture, and/or physical therapy. Some are forced to obtain prescription medication for muscle relaxants or pain relievers, which can be addictive if used long term. Additionally, there is an emotional toll taken as women wrestle with a poor self-image and feelings of shame or embarrassment because of their breasts. To make you appointment less stressful, it is helpful to consider the following before setting up a consultation for a breast reduction:
Your insurance company’s in-network policy
Contact the plastic surgeon you’re considering to find out if your insurance company is in network with their practice. If it isn’t, find out what your out-of-network benefits are.
Your insurance company’s coverage requirements
Find out what documentation and tissue quantities your insurance company requires. Most insurance companies require documentation from a primary care doctor, in addition to a chiropractor or physical therapist, confirming that a breast reduction is medically necessary. Also, insurance companies will also require that a minimum amount of breast tissue to be removed in order for the surgery to be covered. Knowing the required amount will be beneficial during your consultation, since your plastic surgeon will tell you how much breast tissue he or she will remove during surgery.
Considering the symptoms, risks and potential consequences related to this debilitating condition, many people assume their insurance policy will cover “reduction mammaplasty” to reduce the size of their breasts. Unfortunately, this is too often not the case. Insurance companies typically deem the procedure strictly “cosmetic”, and therefore not medically necessary. If they do offer coverage for the procedure, they may require extensive data to substantiate that surgery is necessary. For example, some companies require that a huge amount of tissue be removed before they will consider paying for the surgery. The minimum amount is currently between 700-1000 grams per breast. (There are 453.6 grams in a pound; in a woman of average stature, this would be equivalent to removing up to two pounds of tissue from each breast.) Other requirements, such as medical records documenting months or years of therapeutic and/or medical treatments, can seem equally unreasonable. While the insurance provider may appear to be representing their clients’ best interests, the bottom line is financial. We have had many patients claim that they were assured by their insurance representative that their policy does indeed cover breast reduction, only to have coverage denied later because they did not meet the requirements.
Denver plastic surgeon Dr. Slenkovich and his staff have seen the grief and discomfort this condition causes. We are committed to helping our patients meet their insurance company’s standards whenever possible. However, we now recommend that patients review their policies carefully and ask specific questions if they hope to utilize their insurance for breast reduction. Seek treatment from your primary care provider, chiropractor, or physical therapist sooner rather than later. Have a mammogram. Then obtain all of your medical records and bring them with you to your consultation. These steps will provide the evidence needed to support your case, and could mean the difference between being approved or denied coverage for this important – and life changing – procedure.