breast-reduction

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.

Gulp.

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.

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Keyword Tags: breast reduction, plastic surgery

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Comments

1

I had my ps office presubmit all required documentation and cigna said it would be covered. I got the surgery(so much better) they paid the anesthesiologist, the surgical office, but refuse to pay the doctor, stating he did not remove enough. I was 40DDD. He reomved 800 & 900 grams. Has anyone heard of such a thing: paying part of it? Can anyone help me in my appeal?

Vikki
almost 2 years ago

2

Kudos to all the women who have successfully had a breast reduction paid for through thier insurance. I have been trying to get mine approved for over a year. The problem is not my doctor. It is the insurane company which happens to be cigna. At one point they were saying it was not a covered procedure unless it was a medical necessity. Once all the paper work was submitted showing that it was necessay I was told it was not covered a all. After further research it was stated that because it was proved that it was necessary I would need someone from my HR department to say that it could be covered. When I ask cigna to send the paper work showing this is what I needed they back tracked and told me it was not a covered procedure. I elected to get the flex-spending account to try and save up for the procedure that way and was told that even if I did that, there would be no guarantee that they would approve for it to be paid for out of my spending account. I don't know what else to do without getting deep in debt. ou know we pay all this money for insurance and still can not get the treatment that we are paying so much for. I'm a small frame women with 34ddd breast snd don't know what to do. I'm at my wits ends and suffering through everyday. I do intend to keep trying maybe something or someone will break.

Dee
about 2 years ago

3

It only took me 30 days to get approved by cigna.

ton
over 2 years ago

4

Aiecia (I-e-sha) I feel everyone's pain. I'm fighting against state health insurance. I been denied regular health insurance because of my precondition. I wear a 34 triple d bra. I tried everything. I bought the best bras, i excersise and yes i have to wear 2 bras to do that. I use to run trace in school before that got to this weight. What's worse I will not beable to breast feed because of my other condition. I had a miscarraige and my doctors never helped me with that. I have to hold my breast to go to sleep. I have sharp chest pains consteandly. All I want to do is relive my pain. As other said, they can't buy the proper clothes neither can I. I have to fight everyday with my health and I'm getting tired of it. I should not have to fight with health insurance compaines. It's said because it's not so much the docotors it's these insurance compaines. Goverment don't even try to help. Health companies get to make the choice who lives and who dies. that's why people don't go to the hospital. We can't afford insurance and we damm sure can't afford the medical bills. God bless everyone here and good luck.

Aiecia Jefferson
over 2 years ago

5

I read lots of posts prior to undergoing surgery last october 1st 2009 and i used to get disouraged. It is not that hard if you really need it. I am 5'4, 135lbs and I used to be 34DDD-34E .The key here is the Surgeon. You need to find a good experienced surgeon who is going to be honest with you and tell you exactly how it is. I can say this because I had negative experiences, where i visited surgeons and was promised a call back after contacting the insurance company. Nothing ever happened, whenever I called the insurance company there was always clinical information missing. Finally, I went to a surgeon who looked at me and said "you need it and I am going to get you the approval you need " we talked about the fact that I was receibing therapy for years, on and off of course because I couldnt affor the copayments. He explained to me that every insurance company requires of cleanical information report from a PT , a Chiropractor , a sports med Dr. or anyone who has been trating the problem for them to see that it is an ongoing problem for which the recommended treatment havent exactly worked. On my case I had Aetna, and they require at least 3 months (30+ sessions ) of treatment. This information justifies that the procedure is a medical necesity and not cosmeticts. I had my chiropractor write the report, my primary doctor wrote me a letter and the surgeon put all of that together along with his report. It was submitted on a thursday and my approval came in the following monday. Please if you know tha you really need it, dont give up , it is worth it! Good Luck!

Michelle
almost 3 years ago

6

I am a smaller framed woman who use to weigh 220 pounds, am 5 ft 4 and have weight 135 for over 6 years. Because I am middle aged, I have sagging breasts which are a 42 inch B Cup. but insurance claims I don't have enougn breast tissue to have it removed. I have chronic terrible headaches and neck and shoulder pain. I have been on Vicodin foe 6 plus months. When I hold my breast up with my hands, this relieves weigh on my neck and shoulders, and pain. At this point, I wouldn't mind havin my breast completely removed if it meant getting rid of the pain. That, or I am going to have to have someone perform euthanasia on me, because the pain is that severe!

Lily
over 3 years ago

7

ive been suffering for 20yrs. tryed to get a reduction on the NHS..which my doctors strongley reckomended. but there wasint any funding, as a result of that..so im back to square with the everyday pains as a result im wearing 2 bars to help reduice the pain ..as i get blistors on my shoulders, denting and bruising i guess you proberly heard it all before but its true you can see the marks not too menstion everyday backaches help what can i say if i was like jordan i wish with the money id be on the next operating bed ,but im not just an everyday working class mother that doesnt have the money any suggestions ..............

s n
over 3 years ago

8

I am at the beginning stages of fighting AETNA for this surgery also. I was given the names of 2 surgeons in this field in my area by AETNA. Both of them are no longer in the state. I was told it would be considered a network deficiency and I could use an out of network surgeon. I have begun seeing someone and had a consultation, booked a surgery date and paid to hold the date only for AETNA to say oh with more research we found Dr's in network and are denying the surgeon I have committed to.

A. G.
over 3 years ago

9

My surgeon just submitted a pre-determination for Aetna to request coverage for my breast reduction. My primary doctor as well as the orthopedic wrote a letter recommending the surgery. Obviously it will take more time to find out the results, as this was submitted last week, however I'm looking forward for it to be approved, u guys keep me updated to see if AETNA approved you surgery.

Melissa Tiado
over 3 years ago

10

I am one of these smaller framed women and I feel discriminated against due to the amount of volume that needs to be taken off in order to qualify can and get insurance coverage. I have constant neck pain, and pulling in the neck area. I have DJD of my neck. I have to wear two to three bras to run on the treadmill, and I have these breasts that over flow into my armpits-which makes it difficult to find tops that look nice. I can not buy a dress that fits right because my top is alot larger than my bottom.

Mrs T
over 3 years ago

11

I am waiting to hear from Aetna too. TM keep me posted on what happens and I will as well

tm
almost 4 years ago

12

I am currently going through the appeal process with my insurance company (Aetna). They are terrible, and want you to be practically disabled to have this surgery completed. As Dea stated above, I have been jumping through every hoop to please them...filling out every form... and as an athlete, I have a very small time frame to have this procedure done. I am 20 years old, and am in extreme,debilitating daily pain. If anyone else has any helpful hints in order to speed up the insurance process, please leave a comment. Thank you so much! :)

TJ
almost 4 years ago

13

I fought for over 2 years to finally get my insurance provider (Cigna) to approve a breast reduction surgery. I had jumped through every hoop they had thrown at me and was still denied. I ended up having to contact the California Department of Insurance and provide them with a detailed paper trail of everything that my doctors and plastic surgeons and I had submitted to my insurance provider. It was through their efforts that suddenly Cigna wanted to discuss approving my latest appeal for service. It should not have to take so much to get a procedure that for me was in no way cosmetic but medically necessary.

Dea
over 4 years ago

14

I was wondering if there are any offices that take soonercare patients

Alisa Chaote
almost 5 years ago







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