American Society of Plastic Surgeons
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Breast Reduction

Documentation needed?

Amanda Winter Garden, FL
8 months ago

Hello I mean 38 f and I just recently went to my primary care doctor about my back and neck pain he referred me to a surgeon for a consultation when I called the lady who schedule appointments she advised that I would need to show proof from doctor and chiropractor that this is necessary before I can get a consultation is this accurate I have UnitedHealthcare or should I find another surgeon

Orlando Cicilioni, MD Sarasota, FL
8 months ago

Most health insurance companies require that patients seeking breast reduction surgery have a letter of medical necessity from their primary care physician documenting the presence. of chronic neck and back pain symptoms and that these symptoms have been present for more than 6 months and refractory to conservative management. It is best to have this letter prior to the consultation, because without it you may not even be able to get the insurance company to pay for the initial consultation with the plastic surgeon. In addition to this, women 35 years of age or older generally are required by the insurance company to have a screening mammogram prior to gaining their approval for a breast reduction surgery. Most primary care physicians are familiar with these requirements as breast reduction referrals are pretty common.

Shashidhar Kusuma, MD Plantation, FL
8 months ago

The more supporting documentation you have, the better your chances will be. However, many of us surgeons have become very disillusioned with insurance companies. This has become a game where the insurance companies now use very cumbersome protocols to go through the process all the while without any desire to approve a procedure. This almost seems to be by design to deny authorizations, make the process onerous and painful, and discourage patients and physicians from being successful for such procedures. They often attempt to create antagonism between the patient and the physician by giving hopeful information to the patient and different information to the physician's office.

Having said that, I emphasize the point that the more physician, physical therapy, chiropractor support you have, the bette your chances will be.

Rachel Scott, MD, FACS Danville, IN
8 months ago

Amanda- From what you say, you may very likely be a good candidate for breast reduction surgery. What the office told you is true, insurance (we work with UHC all the time) pretty much always requires that you have proof that you have tried and failed either physical therapy or work with a chiropractor before they will pay for breast reduction. Usually this means working with on this for at least 6 weeks or more, at least once a week. The doctor who referred you to surgery can prescribe physical therapy for you if they are familiar with the process, or in my practice I often see patients to discuss whether they are good candidates for this surgery and then send my folks to physical therapy myself. Every Plastic Surgery practice is probably a little different in how they like to organize it. If you felt that you were getting a run-around from that office, maybe check out another, but know that this is a hoop that you'll have to jump through at some point if you're going with insurance.

Jon Ver Halen, MD Colleyville, TX
8 months ago

Hello and thank you for your excellent question. Surgeons all run their individual practices differently. I personally do not require a referral, but we also do not accept insurance for coverage of breast reduction. It is best to answer your question during a face-to-face evaluation, when you can discuss your goals and expectations for the procedure, and you can have a physical examination to evaluate for that procedure. I recommend that you find a board-certified, or board-eligible plastic surgeon with whom you are comfortable. Be sure to have all of your questions answered during a face-to-face meeting with your surgeon, and review before and after pictures of similar patients whom have had this procedure. If you have any questions, call our office for assistance. Good luck!


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