Why seek approval for payment if you’re not going to follow the requirements? Is there any recourse for a drastic deviation from the insurance requirements? The Schnur scale (recommended by Medicare) puts me at 1.81–1.90 Grams of tissue to be removed per breast 442-527*. However, the surgeon removed 740 gm and 765 gm. I’m trying desperately to wrap my head around what could have happened.
The question is NOT how much tissue he/she removed. It is whether the reduction accomplished the goals of pain control, and you are happy with the resultant size. When I see a potential patient, I tell insurance the minimum amount I believe that I can remove. That could be 450, maybe up to 1000 grams. When insurance approves, they are not requiring that amount be removed. That is the MINIMUM amount to remove. I ALWAYS remove more tissue than I told insurance. Their approval is for a MINIMUM. It is not uncommon that I tell insurance, for example, 600 grams, and have taken off 1200 to 1500 grams, if I feel that is appropriate for my patient and will help with their pain. I pay NO attention to the Schnur scale. The amount the insurance approved was not a REQUIREMENT of amount to be removed, but a MINIMUM!
I agree with Dr> Orr. However the insurance may say the minimum requirement for your weight and BMI is a certain amount or weight. Talking with the patient during consultation may want a certain cup size. I would take enough to meet my patient goals regardless of the insurance requirement. I am treating my patient not an arbitrary number the insurance company has decided without examining the patient and having a consultation with the patient as to her desired final look. (This I consider as practicing medicine without a license). I never tell the patient I will surely meet the insurance requirement and in that case they are full responsible financially, My fees which is discussed in writing and the facility fees.
Insurance companies only require a minimum amount to be removed. It is not uncommon for plastic surgeons to remove more than the minimum like in your case. I always discuss with the patient their desired cup size to meet their aesthetic and medical goals. If you are looking to increase your breast size there are still options for you including fat transfer or an implant. Good luck!
Dear Jamie,
This is really not a conversation for this forum. There are just too many variables for us to form any valid opinion. Your dissatisfaction (as it seems) really needs to be discussed with your operating plastic surgeon. He or she will explain why those amounts of tissue were removed, presumably based on a discussion of your preoperative goals. As mentioned by one of my colleagues, the main question is whether your symptoms of pain, rashes, etc have been alleviated. If the current size is unacceptable to you there are procedures, fat transfer or breast implant augmentation, that may be satisfactory. Good luck!
There is no such thing as a Schnur scale recommendation. It is a minimum requirement that the insurance company requires to determine if they are going to cover the procedure or not. To make sure to meet the requirements the surgeon tells the company a number that almost for sure will be removed by the surgery. This number is most of the times much higher than what was reported. The surgeon has to remove what at the time of surgery they feel is safe and will give the best result with the least amount of possible complications and the difference between 527 grams and 765 grams is very small and what the surgeon felt at the time would be best for the result. It is not a drastic deviation.