Will my breast reduction be covered by insurance?

When you work in the field of surgery, people always want to ask you questions.  More specifically, they want to ask you questions about plastic surgery.  This phenomenon prompted this month’s blog discussion.  I recently was visiting a friend and she brought up the discussion of breast reduction {I didn’t know we were that close ???? }.  She proceeded to tell me she has always been self conscious of her breast and dresses in a way as to not “show them off.”  I proceeded to ask her if she had any symptoms of back, shoulder, or neck pain.  Without hesitating, she emphatically answered, “Ever since I remember!”  I told her she should come in to the office and we could sit down and discuss the details of breast reduction surgery.  Her response was, “Yeah, right!  I wish I could afford it.”  Unfortunately, I’ve heard this response from many women and it’s simply not true.

Women with large breast not only suffer the social stigma that comes along with having large breast, but can have actual physical symptoms.  These symptoms include pain (back, shoulder, neck), headaches, rashes in the folds of the breast (intertrigo), bad posture, exercise intolerance, and bra strap grooving.  These symptoms affect women in their daily lives and make certain activities much harder to perform or enjoy.  This isn’t anything new (maybe to us men) to women who have large breast and have been seeing their doctor, chiropractor, or physical therapist since puberty.  Many of these women have been taking OTC pain medication which helps somewhat, but usually not long term.  As women age, have babies, or gain weight, the breast change and these symptoms can become worse and in some situations debilitating.

Plastic surgeons have been aware of this problem for decades and have helped many women by performing breast reductions.  One such surgeon is Dr. Paul Schnur.  In the early 90’s, Dr. Schnur did a study that attempted to evaluate whether patients requesting reduction mammoplasty did so for cosmetic or medical reasons.  He polled a total of 220 surgeons to gather the data for his study.  His study differentiated women into 3 different categories:  medical, mixed, and cosmetic.  From the data he polled, 78% of women had a breast reduction for medical reasons, 17% for mixed reasons, and 5% for cosmetic.  Based on this information, the amount of breast tissue removed from the right breast, and a women’s body surface area (BSA), he created a scale that placed two percentile lines:  one at the 22nd percentile and the other at the 5th  percentile.  He determined that women who fell above the 22nd percentile line were motivated for medical reasons and those below the 5th percentile were motivated by cosmetic reasons.  All the rest of the women who fell in between the lines had mixed reasons.  Based on this study, his recommendations were that women above the 22nd percentile be approved for their surgeries by insurance and those below the 5th percentile proceed with cosmetic reduction mammoplasties.  The third group of women who fell in between the lines had to be looked at on an individual basis and determination made one way or the other.  This scale is now widely used by most plastic surgeons and insurance companies.

Unfortunately, many insurance companies have adjusted or misused the information from Dr. Schnur’s scale over the years as healthcare costs have risen and insurance reimbursement diminished.  Some examples of misuse include policies that were developed placing a set 500 gram per breast resection amount minimum in addition to using the Schnur scale and adjusting the scale to require larger amounts to be removed in order to meet criteria for coverage.  Years after developing the Schnur Scale, Dr. Schnur released another article addressing the misuse of his scale by insurance companies and the reasons why he developed it.  Over the years, there has also been several studies that have come out in support of the Schnur scale and the algorithm it uses to determine medical necessity.  These studies have found a correlation between the amount of breast tissue removed and symptom relief, even with smaller volume resections and regardless of body surface area and calculated adjustments.   This adds further weight to the argument that patients should not be denied access to surgery based on arbitrary volume restrictions set forth by insurance companies.

We at NSPS realize this is a problem for many women and are committed to helping women with improving their symptoms through breast reduction surgery.  Based on information provided by the patient, our physical assessment, the Schnur scale, and pictures taken at the initial consult, we submit a packet to the insurance carrier for approval.  The insurance carrier will usually respond within 3-4 weeks.  Based on their decision, we either proceed to surgery, appeal, or work on the recommendations of the insurance company.  These recommendations may be several months of physical therapy or even visits with the chiropractor.  Either way, women should feel empowered to improve their health and not hide behind their breast (no pun intended).

If you have any questions regarding breast reduction surgery, please don’t hesitate to call our office (312-266-6240) or email ([email protected]) me for further information.

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