I have spoken in the past that when it comes to dealing with your health insurance company – it is a nightmare. And if you have to do that for cosmetic surgery, be prepared for the mother of all battles. Traditionally, breast reduction surgeries are defined by health insurers as cosmetic. Itâ€™s a definition that often puts patients at odds with health insurers. Payers have difficulty deciding if breast reduction cases are medically necessary.
According to Dr. Skip Freedman, medical director at AllMed Healthcare Management, though, a woman should qualify for the breast reduction treatment if:
- Sheâ€™s worn support bras, taken non-steroidal anti-inflammatory drugs (NSAIDs) and has had years of chiropractic treatments without alleviating her symptoms.
- Her doctor notes that her complaints are typical for a macromastia diagnosis.
According to the American Medical Association (AMA), when reconstructive surgery, such as breast reduction, is performed on an abnormal structure of the body caused by disease, infection, congenital deformity, trauma or tumors, the reconstructive surgery is considered medically necessary and generally done to improve the bodyâ€™s function. (Related: Breast reduction surgery for women of color)
Breast surgery, rather than conservative treatment or weight loss, provides the best chance for a womanâ€™s relief. Additionally, patients who have congenital breast deformity or who have experienced breast trauma, infection, tumors or disease, may also qualify for breast reduction when itâ€™s considered reconstructive. These patients might have Polandâ€™s Disease or cancer, breast drooping caused by dramatic weight loss due to gastric bypass surgery, significant breast asymmetry, or have had a mastectomy or breast lift. (Recommended article: Make sure that you understand plastic surgery risks)
When unsure, the AMA is encouraging third-party payers to refer to such definitions in determining what services are eligible for coverage under the plans they offer or administer, as well as leverage the expertise of Independent Review Organizations for any questionable cases. Independent Review Organizations offer a deep panel of experts that understand the definitions of cosmetic and reconstructive breast surgery and can help payers ensure patient treatments are medically necessary. Independent Review Organizations can also help doctors confirm their diagnosis by reviewing clear documentation and the high-resolution photographs of the breast area and any other areas affected.