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MEDICAL INSURANCE AND BREAST REDUCTION

Female breast reduction is the treatment for enlarged breasts. This can be a medical condition depending on the size of the breast. Therefore, breast reduction surgery is often covered by medical insurance. Medical insurance varies widely and much time and patience must be taken in going through the process. Dr. Delgado has done hundreds of these procedures and his staff is very efficient in the approval process.

Increasingly, insurance companies are basing coverage decisions for breast reduction surgery on internal company medical policies. These policies are presumably intended to distinguish cosmetic from medically necessary reductions. The correlation of insurance company criteria to the scientifically established indications for breast reduction surgery is not strong. The following are some of the criteria that insurance companies use, based on 251 insurance health plans.

Weight of Reduction

The physical weight of reduction necessary to relieve the symptoms of symptomatic breast enlargement is probably the most controversial of all the currently used insurance criteria. Most policies require a minimum reduction weight before extending coverage for breast reduction surgery. The current medical literature indicates that the weight of a breast reduction is not an accurate predictor of outcome and, furthermore, that virtually all patients with symptoms consistent with macromastia benefit from the procedure regardless of the weight of tissue removed, assuming the surgeon removes sufficient breast tissue to make the patient's breasts proportional to her body frame. In spite of this, most insurance companies want to see 500 grams of tissue removed from each breast regardless of the patient’s weight or height.

Symptom Presentation

Many insurance policies require that a patient have specific signs and symptoms such as pigmented bra strap grooving, or intertrigo, to establish medical necessity. The medical literature, however, indicates that patients with symptomatic macromastia, or overly enlarged breast, have a constellation of chronic upper body musculoskeletal pain symptoms, and a determination of medical necessity should not be made based on the presence or absence of any one symptom or sign. The medical necessity for breast reduction surgery is better defined by self-reporting of symptoms than by existing criteria established by insurance companies. The seven predictive physical symptoms are back pain, rashes, bra strap grooves, neck pain, shoulder pain, upper extremity numbness, and arm pain. Successful symptom relief following breast reduction surgery is dependent on the preoperative presence of upper musculoskeletal signs and symptoms, and is not related to the presence or absence of any one particular sign or symptom. Most women with enlarged breasts present with these symptoms and documentation of this greatly aids the approval process.

Conservative Therapy

Many insurance carriers require documentation of attempts at nonsurgical or conservative treatment for symptomatic management before authorizing reduction mammaplasty. These treatments can include support bras, nonsteroidal anti-inflammatory drugs, narcotic and non-narcotic analgesics, chiropractic treatments, weight loss, and physical therapy. Scientific studies clearly show that conservative measures such as weight loss, physical therapy, special brassieres, and medications do not provide effective permanent relief of symptoms. Therefore, the current medical literature indicates that conservative therapy is of no value in treating female breast enlargement.

Obesity

Because obesity is a known cause of back pain, musculoskeletal symptoms caused by enlarged breast or macromastia are often inappropriately attributed to body weight rather than breast size. Clinical studies have shown that macromastia causes a unique set of upper musculoskeletal symptoms separate and distinguishable from those caused by obesity alone. Therefore, obese women with symptomatic macromastia derive as much benefit from breast reduction as do non-obese women. Insurance companies have issues with obesity and breast reduction approval, and may request weight loss by diet and exercise before approval.

Bra Strap Grooving

Some insurers require photographic evidence of bra strap grooving to establish medical necessity. This requirement implies that it is not possible to have symptomatic macromastia unless shoulder grooving is evident. Medical evidence clearly shows that the absence of photographic evidence of bra strap grooving neither rules out a diagnosis of symptomatic macromastia nor predicts a poor outcome from breast reduction surgery. The absence of bra strap grooving should not factor into the decision to cover breast reduction surgery. In spite of these medical findings we always take photos of the bra strap area for the insurance company approval process.

Inframammary Skin Rash or Dermatitis

Some insurance breast reduction medical policies require photographic documentation of skin rashes underneath the breast fold and the failure of conservative treatments for skin rash dermatitis to establish medical necessity. Medical literature clearly indicates that the absence of any one symptom (in this case, skin rash or dermatitis) does not eliminate the diagnosis of macromastia. As part of the preauthorization process we clearly document skin rashes and the medical treatment used, but many women who suffer from enlarged breasts do not have this issue. Dr. Delgado’s office presents a compelling argument regarding this issue.

Age Older than 18

Some insurers require that a patient be older than age 18 to be eligible for coverage for reduction mammaplasty. This requirement implies either that patients younger than age 18 do not suffer from symptomatic macromastia or that breast reduction is not effective in patients under the age of 18. This is clearly not the case and we see young women having breast reduction more frequently due to the devastating effects that enlarged breasts have on one’s life.

Liposuction Breast Reduction

Some insurers specifically exclude coverage for breast reduction surgery under any circumstance for reductions by liposuction. This has been discussed at length in the liposuction breast reduction section.

Mammography

Some insurers specifically require mammograms for women aged 40 years and older before a breast reduction. The medical literature agrees with this completely.

Symptom Criteria

Breast Reduction surgery is considered reconstructive surgery and medically necessary for symptomatic macromastia patients. There are criteria that must be met to acquire medical insurance coverage. However, not all of these symptoms are required. The symptom criteria are as follows:

  • Chronic breast pain (ICD-9: 611.71) due to the weight of the breast(s)
  • Intertrigo (ICD-9: 695.89) or skin rash-dermatitis which is unresponsive to medical management
  • Upper back, neck, and shoulder pain (ICD-9: 724.1, 723.1, 723.9)
  • Backache, unspecified (ICD-9: 724.5)
  • Thoracic kyphosis, acquired (ICD-9: 737.10)
  • Shoulder grooving from bra straps (ICD-9: 738.3)
  • Upper extremity paresthesia (ICD-9: 782.0) caused by brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area
  • Headache (ICD-9: 784.0)
  • Congenital breast deformity (ICD-9: 757.6)
  • Weight of breast tissue resection

Some or many of these symptoms may be part of your history. Dr. Delgado and his staff are experts in getting through the red tape and presenting your case to the insurance company. Once we accept your case we have a very high success rate.

CONSULTATION IS THE FIRST STEP

A personal consultation is the first step for every patient considering a breast reduction. This appointment can be scheduled at Dr. Delgado’s San Francisco or Marin County offices. During the appointment, Dr. Delgado will inquire as to the patient’s concerns about her appearance and the impact her breasts are having on her daily life. A detailed exam will be performed to determine the best breast reduction procedure. A complete history will be taken and photos will be taken.

The consultation will discuss the various types of breast reduction and the technique most appropriate for your situation. Before and after photos of Dr. Delgado’s patients who’ve previously undergone breast reduction surgery will be viewed.

The next step is to submit a pre-authorization package to the insurance company along with all the necessary supporting documents. The response usually takes about four to six weeks. If the procedure is approved, then you are ready to book a surgery date. If the request is denied, we can always appeal to the medical director with a personal telephone call. This can be very beneficial.

Dr. Delgado is a breast reduction specialist. His staff is highly trained in the breast reduction approval process. We welcome the opportunity to provide you with the highest quality in plastic surgery services.

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