Posts Tagged hypermastia

Breast Reduction Insurance Requirements

Breast reduction is defined as the reduction and lifting of naturally enlarged breasts. Medical insurance can cover this surgery but the insurance requirements vary from insurer to insurer. The insurers pay variably as well for surgeons who are Provider doctors and those who are not. Some pay so poorly that I can’t afford to take their rates. You will find few MediCal plastic surgeons in Orange County. There will be very few good ones.

The process for obtaining health insurance coverage generally involves your plastic surgeon writing a Letter of Medical Necessity to the insurer requesting coverage. This should be done before surgery and does not absolutely guarantee coverage, but at least makes it almost certain.

The letter generally needs to have a picture of the woman’s breasts and a description of her problems. Her height and weight and a prediction of the mass of breast tissue to be removed (in grams) are traditionally also indicated.

There are certain ICD-9 diagnostic codes that are pertinent in a letter of medical necessity. They indicate problems for which breast reduction might be helpful. A few that we indicate in our letter when appropriate are:

611.1 Hypermastia – Excessively enlarged breasts
611.7 Mastodynia – breast pain
719.41 Pain in joint; shoulder region, Scapula
724.5 Back pain unspecified

If this letter is successful, a return letter from the insurer indicates a conditional pre-approval. They are always vague on this item. Sometimes the insurer will require physical therapy for a period of time or a weight loss program prior to approval or ask that another pre-approval be sought after non-surgical therapy is tried.

There is no general rule. Each insurer has its own process and they are not forthcoming on exactly what they require. Blue Cross, Blue Shield and United Healthcare are the same only in that they will not tell you how they come to a decision. Some patients are approved and others denied. There is an appeal process in most cases.

Your surgeon should know if you are a reasonable candidate to try for insurance coverage. The worst they can do is say no. :)

Best Regards,

John Di Saia MD

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