American Society of Plastic Surgeons
For Medical Professionals
 
Chellebelle
4 months ago
Answered

How I get deemed medically necessary for a reduction

I just had an MRI and found out I have multilateral degenerative disk disease with facet joint effisions, 2 tumors on my spine, canal stenosis, 8 bulging discs..No suspicious soft tissue mass.

No sizable fluid collections.

No fracture identified.

Hemangioma T12 vertebral body measuring 11 mm.

Hemangioma L3 vertebral body measuring 9 mm.

There is no bone marrow edema.

Bilateral facet joint effision

Procedure: Breast Reduction
Location: Wabash, IN

Replies 2

Rozbeh Torabi
ASPS Surgeon
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It’s dependent on size and shape of breast and how much could be removed to give you relief. Different insurance companies have different requirements. These findings are a great start and your plastic surgeon can further discuss other findings to aid. Some insurance companies require that you have tried nonoperative therapies without any help such as physical therapy, nsaids , and supportive bras.

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Rahul Vemula
ASPS Surgeon
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It depends on the size of your breasts and how much tissue needs to be removed from each breast to achieve your goal. The insurance company has specific criteria that must be met in order to get coverage for the reduction. Unless the insurance criteria is followed to the letter, you won’t get insurance coverage.

Unfortunately some plans may also have plan exclusions where they won’t cover a breast reduction under any circumstance.

Please obtain a consultation with a board certified plastic surgeon who performs breast reductions in order to determine if you are a candidate.

Another thing you can do in the meantime is call the member services phone # for your insurance company and ask them the specific criteria for a breast reduction (CPT code 19318). See if you can get as policy document or SPD that will speak about specific criteria. Every time you speak with someone from the insurance company ask for their name & ref # for the call.

Best Wishes!

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