Posts Tagged breast reduction

Medicare Denies Breast Reduction

For years I have avoided Medicare breast reductions for a number of reasons:

(1) Poor pay for hours of work. An average breast reduction when done to a high standard usually takes 3-4 hours. I do not staple the closure.
(2) Medicare patients due to their age are at higher risk for wound healing problems.
(3) 90 day global fee period – These patients routinely need follow-up care and that care is not billable.

Recently I ignored my better judgment and performed the operation for a lady in whom back pain (ICD-9 724.5) and back surgery had been long term problems. She also had a pretty nasty rash (ICD-9 692.89 Dermatitis and eczema [in the infra-mammary fold]) under her right breast that just wouldn’t go away. These of course were all in addition to the usual diagnosis of large breasts (ICD-9 611.1 Hypertrophy of breast.)

Medicare showed me yet another reason for my hesitation to do these cases when they denied payment for the operation saying it was not medically indicated. They will probably pay on appeal, but the thought that I should have to appeal the case adds insult to injury.

Best Regards,

John Di Saia MD

Originally posted 2010-06-01 07:30:04.

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Our History with Free Cosmetic Consultations

Once in a while (fortunately very infrequently in my practice) people get bent when they get a bill. I used to offer free cosmetic consultations, but people often came to just “talk” which became too much of a waste of time. My overhead does not stand silently in the corner while people just talk. Some people may have also had a hard time understanding what a cosmetic consultation is exactly. Now I do free consultations as occasional promotions, but generally we charge something.

For the purposes of a “Cosmetic consultation:”

If your health insurance is involved, it is not cosmetic. Health insurance excludes cosmetic surgery except under very specific circumstances.

Some women have initially come in for a cosmetic breast consultation and then tried to switch when they were in the office to having their insurance cover their breast reduction. While this is not a problem for the office, it does make the issue non-cosmetic because you are telling your insurance company you “need” your breasts reduced for medical reasons.

We don’t charge much for cosmetic consultations and credit this towards a patient’s surgery if one follows the visit. The charge is actually much less than we bill insurance for a regular consultation although the paperwork and hassle is of course much more with an insurance company.

Best Regards,

John Di Saia MD

Originally posted 2011-09-29 07:30:03.

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Reader Question: Ugly Breast Lift and a Mass – How to Avoid / Fix?

I have been considering fixing my saggy sad boobies (two children, breastfeeding – blah. blah. blah.) Then I find this image online of a woman who had a lift with ugly scars and a new lump in her breast. This scares me. How do I get pretty boobies without the scars and lumps this lady got?

Plastic surgery comes with risk. Although the scarring you see here is not typical, it can happen and require surgery to fix. Of course poor scarring occurs more in certain practices than others and in patients who are less healthy and/or smoke more than in others. Compared to what we see in this case, the Katie Price breast lift scar drama kinda pales in comparison. All things are relative when we look closely enough anyway.

This lady you mention has two issues… scars and lumps. They may or may not be related.

(1) Scars – She shows her right breast in your image with a thick irregular scar in the healed incision at the inflamammary (under breast) fold. This looks amenable to scar revision. Her vertical scar between her areola and her lower breast scar is a bit wide as well. I would probably recommend scar revision surgery once these scars had matured and softened. Widened scars are particularly amenable to well performed scar revision more than some of the other treatment options.

(2) Lumps – Breast lift and reduction can result in scarring under the skin and in the breast that feels lumpy. These need to be carefully evaluated to make sure they are really just scar and not cancerous lumps. Fat necrosis after a breast reduction in particular can manifest in lumpy scars that become smaller over the first year from surgery. They can be removed if need be to prove that they only represent scarring and not something more worrisome.

How do you avoid these?

You can limit the problem by picking the right doctor, not smoking and having the right genetics.

Best Regards,

John Di Saia MD

Originally posted 2011-06-27 07:30:15.

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Blue Cross Breast Reduction Denial After Pre-approval

Healthcare insurance companies are on my short list for contempt.

They underpay, take forever to pay, deny after approval and rescind for fun. Why should I not pitch them the BS they deserve in return?

Today I received a particularly funny (and O-So-Typical) letter concerning a woman for whom I performed breast reduction a few weeks ago. This case was the largest I have done this year with over 4 pounds of breast tissue in the removed specimen. Her back pain is gone. She can stand up straight. And her husband looks like an worked-up fiancé (amongst the best compliments in my book).

Bottom Line: This case was medically-indicated and I did a great job. Sorry Blue Cross.

Nevertheless, Blue Cross via letter issued a denial/delay of payment after the surgery had been performed (and after their own pre-operative approval). They are trying to make payment the responsibility of the HMO arm of her insurance plan. I am not an HMO provider. They know it won’t work, but it will delay payment.

This is Health care Insurance Company B.S. Maneuver #1 from the “We’re Cornered But We Can Still Delay The Payment” chapter.

They know this abuse is amongst the reasons doctors drop insurers. I can certainly see why many of my friends have done so.

More of that wonderful treatment from your insurance industry.

Best Regards,

John Di Saia MD

Originally posted 2005-06-30 20:09:00.

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Reader Question – Breast Reduction and Post-op Fullness

I am going to have a breast reduction soon but have always loved my breast fullness. Is there a way that they can be reduced and remain full?

Young women with particularly large breasts retain some of that fullness after breast reduction, but it does vary with the technique and target size. This is something to discuss with your surgeon before surgery and to confirm with some images of patients he or she has previously operated.

Take into account that larger reduction results have more of a tendency to become droopy as well. Gravity has a tendency to win if things are left too large.

This one like many thing in plastic surgery is relative….relative to how
small you go and how exactly it is done.

Best Regards,

John Di Saia MD

Originally posted 2010-03-31 07:30:24.

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Good Plastic Surgery in the OC – Quality Breast Reduction

Orange County Breast Reduction Before and After

Six years or so before “A” came for consultation, I had done her friend’s breast reduction. “A” is petite and had some of the common pre-operative complaints that good breast reduction candidates report…upper central back and shoulder pain. She did not enjoy having to “scoop her breasts into a bra every morning” either. Two months after her surgery her pain was gone and her incisions healing well. She is pleased with her good results having had only 220 grams removed per side.

Best Regards,

John Di Saia MD

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Husband Opposed to Wife’s Breast Reduction

Jeanette’s story:

For as long as I can remember my nickname has been ‘Jen Big Boobs’. Friends joke that the first thing they see when I walk through the door is my chest. I know they mean no harm – just as ­­I know that my husband, Steve, adores them ­­– but it’s reached the point where they have ­­got to go. They simply dominate my life. Whether I’m trying to get comfy in bed or walking down the street I can’t forget them for a moment. They are always there, getting in the way of everything I do. In primary school I was the first in class to wear a bra. So when my pals changed in the classroom for PE, I’d change in the loos. Big boobs weren’t a huge surprise – they ­run in my family. But it was embarrassing and ­I didn’t like being different. They’ve singled me out for loads of attention. Buying bras has always been and still is a nightmare. I have to order specially-made ones that are ugly and cost up to £50. By the time I was 20 I’d already gone to see ­my GP about a reduction operation. He was ­sympathetic but said I was too young for ­surgery.

Steve’s story:

I love my wife’s big boobs and don’t want them reduced. I don’t mind admitting that I ­adore Jen’s boobs. She has an amazing figure. I defy any man to say he doesn’t love big breasts, especially when they are as ­firm as hers. Even women would love to have Jen’s ­body – and many pay to have their ­boobs enhanced not reduced.While I know it gives her backache I love her chest and it makes me so sad she wants to change herself this way. For a start, I feel her breasts define her. I’m not just worried she won’t like her new figure afterwards – my primary concern is that it’s a big operation. As well as being expensive, it isn’t a straightforward procedure. There’s always a risk with general anaesthetic and ­I worry something could go wrong. I’ve read horrifying stories where women have contracted life-threatening infections or ended up with no nipples afterwards.

Source: mirror.co.uk/life-style/real-life/2011/10/27/
i-want-a-boob-reduction-but-my-husband-won-t-let-me-
115875-23517427/

Men are at times worried about their wives and the effects of plastic surgery. Significant others of breast reduction patients at times may fear the loss of their beloved breasts. I have seen this a few times over the years. Interestingly when they later realize that their wives’ breasts have not been removed, but reduced and also re-shaped, many of those same men have been pretty damn happy. :)

With that being said, Steve’s being a bit selfish here. If Jen’s miserable with those larger than large breasts, why should he not vote for her comfort? The fear of the procedure might be genuine, but in the right hands on a healthy patient the operation is pretty low risk. There are always the very rare circumstances that could come about, but most plastic surgeons do not see such an event throughout their careers.

Steve’s got guts though. To say something like her boobs define her would get many men a long trip to the couch.

Best Regards,

John Di Saia MD

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Reader Question: Breast Reduction Wound Separation Help!

Reader Question:

I had a breast reduction by another Orange County doctor three weeks ago. My wound is coming apart and he says don’t worry, so I am worried. What should I do?

Breast reduction surgery is usually a low key event at least when the patient is healthy and her surgery is done by a qualified surgeon. There are cases in which the wound(s) can have a little trouble healing especially at the t junction at the base of each breast. These problems are not universal, but are more common in older patients who smoke or have smoked. Small separations occur in about 8-10% of my breast reduction patients and heal uneventfully. I follow them closely in office visits while this happens to make sure we can optimize the healing.

What do you do about a wound separation?

Make sure your surgeon sees it as early as possible. Small ones do heal. Healing can take a few weeks to a few months and can affect the results of surgery more significantly when they are larger. The key is professional guidance on your particular wound. Unless the wounds are infected, antibiotics are not much help. Sometimes a stitch or some non-healing tissue must be removed. Let your doctor do this.

How do you help prevent wound separation after breast reduction?

(1) If you smoke, stop and let your doctor know about it when you are seen before surgery. Smoking increases your risk, but stopping before (and after) surgery for a while can decrease that increased risk somewhat.

(2) If there is any question, get medical clearance from your primary care doctor before having the breast reduction surgery. Ask about prospective healing.

(3) Get a good qualified surgeon and follow his or her advice.

Best Regards,

John Di Saia MD

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Breast Reduction in Orange County : Current Status

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.

Best Regards,

John Di Saia MD

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Painful Lumps After Breast Reduction?

After breast reduction surgery it frequently takes a while for the healing to be complete. During the process of healing, scar tissue can form along the incisions and also within the breast (fat necrosis.) Your body usually improves this scar tissue in a process called scar remodeling over the course of the first year to 18 months. If there are areas of discomfort afterward, a re-evaluation is appropriate to determine whether or not anything can be done to improve the result.

Not everyone gets these scarred uncomfortable areas. They are more common in larger reductions and in smokers.

Best Regards,

John Di Saia MD

Related:

Dr D’s Web Site Breast Reduction page

Originally posted 2010-01-28 07:30:23.

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