Insurance coverage has gotten more difficult over the years. When I started my practice, most of my reductions were covered by insurance. Now most are not. I believe the act of lifting and reducing the breast helps with neck and back pain, posture, ease of dressing, and ability to exercise. You can check with your insurance to see if “reduction mammaplasty” is a covered surgery with your plan. All plans are different, even within the same insurance company. If you have seen other doctors such as a back doctor, physical therapist, or chiropractor for neck and back pain, a letter from them supporting a medical benefit in your breast reduction is helpful. A minimum reduction of at least two breast cup sizes is necessary. With current recommendations, a 5’6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered. If she weighs 160, she would need about 450 grams per breast. Liposuctioned fat cannot be applied to this total. In the office I can show you with sizers the approximate amount. For some of my patients, the “minimum” needed to be removed is almost a mastectomy.
Please read below for a sample of an insurance letter to understand what we face now. We are happy to help the process with photos, letters, and the coding. I am your advocate.
“Reduction Mammaplasty for symptomatic breast hypertrophy or hypermastia may be considered medically necessary when the documentation provided shows that the member meets all criteria of our medical policy.”
– Clinical documentation of pain in the upper back, neck, and shoulders which is long standing in duration and increasing in intensity, and is not related to other musculoskeletal causes (eg poor posture, acute strain, post traumatic conditions, poor lifting techniques. or over use)
– Clinical documentation of ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and hands.
– Physical exam documenting hypertrophy.
– Clinical documentation showing failure of a minimum of 6 weeks of physical therapy for back, neck or shoulder pain including a maintenance home exercise program.
– Clinical documentation showing failure in the use of an appropriate support bra with weight distributing straps.
– Clinical documentation showing failure in the use of anti-inflammatory agents, unless medically contraindicated.
– Clinical documentation showing failure in the use of symptomatic measures, including the application of heat and cold.
– Documentation of the patients body surface area based on the Schnur Sliding Scale, where the patient’s breast weight per breast is estimated at greater than the 22nd percent line, consisting of breast tissue, not fatty tissue to be removed.
(Dr. Greenberg note: You can see the body surface area calculator at http://www.bcbst.com/providers/calculator.asp )