Unfair Insurance Coverage Practices Applied to Breast Reduction Surgery?
By Brian Cole
Published on November 14, 2007
Imagine for a moment you have constant, debilitating headaches. You wake up every day knowing you’ll experience pain. You go to work: headache. You exercise: headache. You meet friends and, yep, you got it: headache.
Now walk a bit farther down this imaginary path. It eventually leads to your doctor’s office. It turns out there’s a procedure that — with incredible certainty — can relieve your pain. Sweet freedom!
But wait. It turns out that this procedure costs a pretty penny and — oops — it’s not covered by your insurance. Well, how much could it cost, right? The answer: $5,000 to $7,000.
Seeking Relief from Everyday Pain
In reality, thousands of women seeking breast reduction surgery have found themselves in scenarios very similar to this. These women experience pain, can’t afford breast surgery on their own, and don’t meet the requirements for coverage laid out by their insurance carriers.
A few recent studies, however, have helped to create a consensus among many surgeons that insurance coverage requirements regarding breast reduction surgery are arbitrary and even unfair.
A study published in the September 15, 2007 issue of Plastic and Reconstructive Surgery offers some insight into the situation many women are facing. It finds that insurance coverage is often denied to those who would experience significant health benefits from breast reductions. Currently, most insurance carriers refuse to cover breast reduction procedures in which less than 500 grams of tissue per breast are removed.
The problem, according to the study, is that many insurance carriers fail to review the full range of factors that are in play. Breast reduction procedures in which less that 500 grams of tissue are removed may offer an important reduction in pain — and significant quality-of-life benefits — to smaller-framed women, the study found.
The Body Type Dilemma
It all comes down to a question of proportion. If a woman has a small body type, she can experience the same benefits from surgery with significantly less tissue removal. Although a smaller woman’s breasts will likely have less volume than a larger woman’s, this doesn’t mean women with smaller frames don't experience pain. In fact, the study showed they often do.
Most insurance carriers contend that smaller women are seeking breast reductions for cosmetic reasons. Since strictly cosmetic procedures are not covered by insurance, this would free companies from having to pay for such treatment.
Another study serves to debunk this assertion. Reduction Mammaplasty: A Review of Managed Care Medical Policy Coverage Criteria was originally presented in 2006 and reviewed the coverage criteria for breast reduction surgery in 87 health insurance policies. These criteria were then compared to the indications for breast reduction procedures outlined in medical literature.
Startling Findings... And Hope for the Future
The researchers were unable to identify a single insurance policy that was entirely supported by the medical literature. Worse, many coverage policies were found to be “completely unfounded based on medical literature” and “arbitrary and without scientific basis. Not good.
The study described “invalid guidelines” being used by the insurance industry, including requirements regarding the volume of breast reduction, minimum age, maximum body weight, and a trial of conservative therapy. These guidelines appear in the majority of managed care policies, to the consternation of surgeons.
While these requirements continue to be applied, both surgeons and those who experience daily pain are hoping studies like these will make breast reduction surgery more accessible to those who need it.