Letter For Insurance Company To Pay For Breast Reduction

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Breast reduction surgery is one of the most popular procedures performed by plastic surgeons in the United States and has been shown to be effective in reducing symptoms and improving the quality of life for women with heavy and sagging breasts. In fact, the American Society of Plastic Surgeons reported more than 103,000 breast reduction procedures in 2013.

If you suffer from neck and back pain, a painful slitting in the shoulder from bra straps, headache, difficulty purchasing clothes, and difficulty participating in sports activities, you may be an excellent candidate for the so-called “medically necessary” breast reduction procedure. Most insurance companies cover this. Action. However, each holder uses different criteria to determine whether or not their breast reduction surgery will cover them at all.

If you are considering breast reduction surgery, first read your insurance policy. If your insurance company does not provide coverage for breast reduction, you may not even be covered to consult with a plastic surgeon to discuss your options. Most insurance companies will look at a woman’s reported symptoms, the duration of symptoms and how these symptoms have affected her quality of life. It is important for you to discuss your concerns with your primary care physician and document your symptoms in your medical record. Letters from your primary care physician, orthopedic therapist and / or physical therapist can be invaluable “evidence” in building your case for prior authorization for breast reduction. These documents, when included in a package with a letter and photos from your plastic surgeon, will help you obtain clearance from your insurance company before scheduling your surgery. This is a necessary step, as the insurance company may refuse to cover the costs associated with the surgery if the procedure is not authorized in advance.

It is common for insurance companies to require a certain amount of breast tissue to be removed from each breast for the breast reduction to be considered medically necessary. The weight of the breast tissue to be removed is determined (for insurance approval) based on your height and weight, but this weight requirement often conflicts with a woman’s aesthetic goals. Insurance companies don’t care which way they look, despite the well-known fact that physical appearance can have an impact on quality of life. Despite the medical literature demonstrating that breast reduction surgery improves a woman’s quality of life regardless of the weight of the tissue removed (Spector and Karp, 2007), a recent report by Koltz, Frey, and Langstein (2013) revealed that 86% of insurance providers who were included The survey still used a chart based on the 1991 Schnur Sliding Scale that compared a woman’s drive for breast reduction and her weight.

The Schnur scale recommendations are derived from a survey that asked plastic surgeons about their perceptions of whether their patients’ motivations for breast reduction are reconstructive or cosmetic (Schnur et al., 1991). The survey should not be taken (even among surgeons) as scientific evidence. Years later, Schnur himself challenged insurers ’misuse of the scale and indicated that the scale should not be used as a standard for insurance coverage (Schnorr, 1999).

Each person responds differently to physical symptoms, and breast reduction is not a term that should be defined by a number, but rather it needs to be viewed in the context of a woman seeking to improve the quality of life. If you disagree with your insurance company’s decision, you have the right to appeal.

Being a good candidate for surgery also means that you have a comprehensive understanding of the condition being treated and the intended procedure. Breast reduction is one of the most satisfying procedures we perform for patients. If you feel that large breasts are interfering with your daily performance, ask to visit at least one plastic surgeon certified by the American Board of Plastic Surgery to learn about your options for breast reduction. Your family, personal doctor and experienced plastic surgeon can help you make the right decisions for you.

Additional Resources / References:

1. Spector JA, Carb NS. Breast reduction: a major improvement in any size. Plastic reconstructive surgery. 2007; 120: 845-850.

2. Koltz PF, Frey JD, Langstein HN. Insurance Coverage and Breast Reduction: A Systematic Review of Current Healthcare Policies. Plastic reconstructive surgery. 2013 Oct; 132 (4): 692e-693e.

3. Schnur, PL, Hoehn, JG, Ilstrup, DM, Cahoy, MJ, Chu, CP Breast reduction: plastic or reconstructive procedure? that. Plast Surg 27: 232-237, 1991.

4. Schnur, PL Reduction mammaplasty – A sliding schnur scale revisited. that. Plast Surg 42: 107-108, 1999.

5. American Society of Plastic Surgeons. http://www.plasticsurgery.org

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