Reduction of the female breast: Obtaining insurance coverage of reduction mammaplasty

As I explained in my previous post, large breasts (macromastia) can cause physical problems that interfere with a woman's daily functioning. Symptomatic macromastia is a well-recognized medical condition requiring therapeutic management. Because heavy breasts cause constant strain on body structures, insurance coverage of reduction mammaplasty is as appropriate as, for example, coverage of cervical spine surgery, shoulder surgery, carpel tunnel release, or sleep apnea treatment. For some conditions, non-surgical treatments should be tried first, but unfortunately there are no non-operative treatments of macromastia likely to provide long-term or permanent symptom relief.

If you are considering breast reduction surgery, first read your insurance policy. If your insurer lists reduction mammaplasty as a policy exclusion, you may not even get coverage for a consultation to discuss whether surgery is appropriate for your symptoms.

In most cases, insurers require the surgeon write a letter describing the patient's symptoms and physical findings, estimating the breast weight to be removed, and requesting coverage. This should be done prior to scheduling surgery because the insurer may not be obligated to pay if surgery was not preauthorized. If your insurer denies coverage by labeling breast reduction surgery cosmetic, your doctor must educate the insurer about symptomatic macromastia and explain the difference between breast reduction and its cosmetic cousin, breast lift. Preauthorization may not be available in traditional Medicare and Medicaid plans.

Up-to-date insurers should be familiar with the current standard of care for treating macromastia, and should approve coverage based on reasonable criteria and documentation of medical necessity. Unfortunately, too many insurance companies do not yet consider the last two decades of medical literature proving the effectiveness of breast reduction surgery in relieving symptoms of macromastia regardless of a woman's body weight. Many of these companies use a chart based on the 1991 Schnur Scale that compared a woman's motivations for breast reduction and her body weight. Many women are denied coverage because of where they fall on the chart. Recent medical literature has shown that use of such a chart to discriminate against overweight women by denying them coverage regardless of their symptoms has no medical justification, yet insurers continue to do so.

Determination of medical necessity should be based on your doctor's report of your symptoms and physical changes caused by your breast weight. Even though trials of non-surgical treatments may have little chance of success, they may be preconditions for insurance coverage of surgery. It is not unreasonable for an insurer to require a minimum weight of breast tissue be removed, but there should be a mechanism by which special circumstances (for example, a small-framed woman or a woman with a medical condition aggravated by even moderate breast weight) receive extra consideration.

If you get a denial and feel that breast reduction is necessary for your health and well-being, you are legally entitled to appeal. The appeals process should be described in the denial letter. In most cases, multiple levels of appeal are available, and you should take advantage of them. Letters from a family doctor, orthopedist, physical therapist, chiropractor, or massage therapist can help support an appeal. You should write your own letter describing your symptoms and how they have limited your life (focus on your physical problems rather than your difficulty finding a bathing suit). Ask your doctor to submit your personal letter, supporting letters, up-to-date scientific information about the standard of care for treating symptomatic macromastia and a list of medical literature references with the appeal.