BREAST REDUCTION WEIGHT REQUIREMENTS BY INSURERS

Insurers typically rely on a number of things to establish whether your reduction surgery qualifies for coverage.

1. Medically indicated signs and symptoms – insurers rely on special references of medical problems under the International Classification of Diseases (ICD) codes. Some of the physical symptoms that may be recognized by insurance companies in relation to excessively large breasts include postural backaches, upper back pain, neck pain, skin irritations (intertrigo), and pressure causing numbness.
2. Body mass index – the BMI is a special system that compares the weight and height to establish an individual’s weight status. Some companies may refuse to pay the bill for breast reduction surgery unless the patient’s BMI is less than 30. Others will only accept BMI that is less than 35, while some companies require documented proof that the patient has tried to lose weight either through exercise, diet, or weight loss surgery.
3. The weight of tissue to be removed – insurance companies will also rely on the amount of tissue to be removed from each breast to determine whether or not the reduction patient qualifies for coverage. Depending on the company, this weight requirement may be 450 grams, 500, or even 600 grams. Some insurers leverage a much more detailed approach to ensure they do not penalize patients with a smaller stature but disproportionately large breasts. 90 percent of times when the patient meets these weight requirements, coverage is provided. Women who have DD, DDD and H cups typically qualify.
4. Matching reduction after breast cancer – coverage is provided in cases where the patient needs to have reduction surgery to balance a larger, healthy breast with one that was affected by cancer treatment. This is provided for by the 1998 Women’s Health and Cancer Rights Act. The legislation covers reconstructive treatment on a breast affected by cancer, as well as balancing procedures for the healthy breast to match the reconstructed one.
5. Evidence from other physicians – before you even get to your breast reduction in Scottsdale AZ from a surgeon, your insurer may require that you provide supportive letters from other physicians requesting breast reduction to treat macromastia symptoms. Letters documenting alternative remedies such as physical therapy, weight loss, and exercising in an attempt to correct the situation will also suffice.
6. Photographs and measurements – your breast reduction surgeons may need to provide de-identified photos (from the neck down) and specific measurements quantifying your breast size in relation to your frame.

If you feel like you may be a good candidate for breast reduction coverage, get in touch with your insurance carrier and ask them to forward (in writing) the criteria for coverage. Different insurance companies have different indications and criteria. Also, keep in mind that it takes about 3-6 months (on average) of preparations before you can seek the insurer’s intervention. This preparation entails consultations with other practitioners for alternative remedies such as chiropractic or physical therapy.