Breast reduction is misunderstood online. The operation is defined as the reduction and lifting of breasts. This is not the same as removing or reducing the size of breast implants in a woman’s breasts. That is called an implant exchange.
Implants are not usually involved especially when an insurance company is scheduled to pay for it with the possible exception of surgery to reconstruct a woman’s breasts after breast cancer surgery.
It is difficult enough to get most insurers to pay for “clear cut” medically-necessary plastic surgery. Breast reduction surgery is the reduction of naturally enlarged breasts and that is all.
Breast reduction used to be one of the more common insurance-covered procedures in my Orange County plastic surgery practice. With the economy as of late, insurers are not always so quick to approve them, but for the right patient they are still do-able.
Usually we see our patients for a consultation and then apply to their insurers for pre-approval if the cases seems reasonable by insurance company standards. We don’t make the rules on approval, but we do know the game. Appeals are not uncommon.
These days insurers are looking for a certain amount of breast gland to be removed in a certain sized woman in order to allow coverage. In addition they like to see documentation of things like bra strap furrows, the “dents” some larger breasted women get in their shoulders from breasts weighing against them over the day. Insurance pre-approval usually covers surgery for a 90 day period. The exact nature of that coverage varies by the plan.
Insurers don’t tend to like claims is which liposuction has been involved. This can trigger denials on cosmetic grounds at the time of billing. In cases of breast implants in larger breasts, we have staged the surgery to avoid insurance denial. That means taking the implants out in one operation and waiting several months to a year before re-operating for breast reduction. It might sound silly, but again we don’t make the insurer’s rules regarding payment.
John Di Saia MD