American Society of Plastic Surgeons
For Medical Professionals
 
sissya
2 years ago
Answered

Getting insurance approval

I was turned down by my insurance company for a breast reduction because the amount the Dr. would remove did not comply with the insurance company guidelines. The amount to be removed was too low at 350 and the insurance required 500. Is it possible another surgeon would recommend the 500? Should I shop for a surgeon who might recommend the 500?

Procedure: Breast Reduction
Location: havertown, PA

Replies 5

Debra Johnson
ASPS Surgeon

Insurance companies require breast reduction tissue volumes that have no basis in reality. Studies have shown that women undergoing breast reduction achieve symptom relief no matter the volume of tissue removed. The difference between a 350 reduction and a 500 reduction is about one cup size. So a 500 reduction would take your breast size down about 3 cup sizes. If that is acceptable to you, then ask your surgeon to resubmit your request for surgery with that volume. If that would make your breasts disproportionately small, then request an appeal of your insurer, and write them a letter detailing your symptoms. Good luck.

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Alfred Antonetti
ASPS Surgeon

Your surgeon recommended the amount to be removed that would look the best for you. If you would be happy with the extra removal of tissue and wanted to be smaller than recommended then most likely it would be ok to do it. If you do not want to be that small then you could consider a mastopexy (lift) but this is not covered by insurance. The insurance companies have certain guidelines that they follow and the physician and patient need to be honest with them end not misrepresent what they intend to do.

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Kimberley O'Sullivan
ASPS Surgeon

The answer to question is YES- you should get a second opinion and see if another doctor believes they can remove the 500 g. I’ve had many patients who have come to me who were told there was not enough breast tissue yet my exam revealed significantly more than the minimum. Also, I have had many patients who requested I remove as much as was necessary to meet the insurance minimum, and they were left with ample tissue to create an aesthetic and full mound. Breast weight is affected by density which typically decreases with age, pregnancy, & breast-feeding , but not always, so an exam will help to determine if you can meet that minimum & leave the aesthetic and size you are looking for. The sunny side up breast after a reduction is so aesthetic you’ll be very thrilled. Good luck!

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Joseph Mlakar
ASPS Surgeon
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It is becoming more and more difficult to get insurance approval for breast reduction surgery. You may wish to consider financing, and paying for breast reduction surgery on your own. If you find a surgeon who agrees to remove 500 grams per breast to meet your insurance approval, you may not obtain the breast size and shape that you desire. Talk to a few of your local plastic surgeons, and find one you trust.

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Yhelda De Alencar Felicio

It is possible to remove breast tissue that it is necessary to remove. See my page: www.yheldacirurgiaplastica.com.br Today it is possible to reduction the breast axillar via, that avoid scar in breast, the scar find in axilla, only.

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