Breast reductions are a very common and popular plastic surgery procedure. It is also one of my favorite operations to perform, especially because women are generally so pleased after surgery. The information provided is meant to help explain the financial aspects of the breast reduction process, as it is sometimes covered by health insurance, as opposed to many other plastic surgeries, which are deemed cosmetic in nature.
By way of background, breast augmentations, lifts, and small volume breast reductions are considered cosmetic or not medically necessary in most instances. (Exceptions to this, however, include a prior history of breast cancer.) Additionally, some insurance companies have exclusion clauses for breast reductions surgery, meaning that the surgery will not be covered, no matter what!
All that being said, we always try to work with a patient's insurance company to see if we can get coverage for a reduction. To streamline and facilitate the process, we are providing the following information to help prevent any delays once you have decided to move forward with a breast reduction. Insurance companies approve breast reductions that they feel to be medically necessary. In making this determination of medical necessity, documentation must be provided explaining symptoms such as back, neck, shoulder pain, and rashes, felt to be attributable to the enlarged breasts. While our office provides information, many insurance companies also require referral notes or letters from the patient's primary care physician and or OBGYN. This referral should include information that the symptoms related to the enlarged breasts have not responded to conservative measures such as support bras and OTC medications. Some insurance companies also require prior evaluation and or treatment by a chiropractor, physical therapist, or orthopedic surgeon.
Providing such documentation at the time of your initial consultation for the breast reduction helps shorten the time to obtain the precertification and often helps avoid denials. Lastly, the insurance company will likely base their decision at least in part on the Schnur table.
This is a tabulation that estimates the amount of breast tissue that needs to be removed based on a patient's height and weight. As part of the documentation our office provides to the insurance company is an estimate of how much tissue is expected to be removed. And unfortunately, some insurance companies will not cover the reduction in the setting of obestity, regardless of the weight of breast tissue expected to be removed. We also accept Medicare, but unlike private insurance, where we request a precert, traditional Medicare does not grant precerts. (However, Medicare Advatnage Plans DO use and require precerts).
It sometimes feels as though it is like playing Russian Roulette as to whether Medicare will pay for a breast reduction. As a result, we use the ABN system. Attached is a copy of a typical ABN form. It may seem complicated, but my staff is happy to explain ABN's it if you should have any questions. We hope this helps answer some of your questions, and we have also attached a copy of our breast reduction information sheet that gives more information on the medical aspects of the procedure