I’ve covered some of the aspects of breast reduction surgery in previous posts, including complications, scarring, breastfeeding after breast reduction, and how the operation is actually performed. Today I’m going to cover the process of obtaining insurance pre-approval.
One of the most common questions I hear about breast reduction surgery is: “Where do I start?” If you’re at this point, the first step is a visit to your primary care physician (PCP) or Ob-gyn. He or she will evaluate your symptoms to see if they might be caused by large breasts, as well as ensure you are healthy enough to have surgery. The next step is seeing a Board-Certified plastic surgeon for an evaluation. This evalation will consist of several parts:
- History of symptoms and the treatments you have tried. Insurance companies will only cover breast reduction if it is medically necessary. They require that you have symptoms caused by large breasts (e.g. neck pain, back pain, rashes under the breasts) that have not improved with non-surgical treatement. These non-surgical treatments might include physical therapy, ice or hot packs, wearing a sports bra, or even losing weight. This is why that first visit to your PCP or Ob is so important; it starts the process of documentation necessary to obtain insurance approval.
- Basic health history. Some conditions, including diabetes and smoking, increase the risks of complications during breast reduction surgery. Your plastic surgeon will take a full health history to look for any medical issues.
- Physical exam. The second part of obtaining insurance approval is being able to remove enough tissue. Your plastic surgeon will estimate how much tissue he or she can remove during surgery, and submit this number along with the request for preapproval. Photos will also be taken to send to the insurance company.
After your evaluation, your surgeon will gather together any supporting evidence. This will include notes from your PCP or Ob, as well as evaluations by any chiropracters or physical therapists you may have seen. This information will then be submitted to your insurance company. There are a couple special circumstances that may come in to play at this point in the process.
- We find out your insurance company does not cover breast reductions- i.e. they are an excluded procedure. Some insurance companies do not cover breast reduction for any reason, even if it is medically necessary. For this reason, I recommend making a phone call to your insurance company before you see a plastic surgeon to confirm breast reduction is covered under your policy.
- You have Medicare. Medicare does not allow physicians to obtain preapproval for surgery. Instead, the surgeon does the operation if he or she thinks it is medically necessary, and then Medicare decides whether or not to pay. Thus if you have Medicare, your surgeon may have you sign a document stating that you are responsible for any charges or fees if Medicare does not cover your care. Make sure you know how much these charges or fees might be before you sign anything.
If neither of the above apply, then your insurance will either approve surgery or not. It usually takes 2-4 weeks to hear back from insurance after the request for approval has been submitted.