After watching “The Other Half” today, I am seriously considering getting a breast reduction.
There was this girl in her late twenties and she has a farely large bust size and she decided to get a breast reduction. She mentioned that her Insurance Company is covering the surgery. When I heard this, I was instantly interested in finding more about how I can get my Insurance Company to pay for this.
You see, I am twenty nine, I have one child, and for a lack of better words, I am huge. I have always been bigger on top than bottom. I have permanant indents in my shoulders from my bra, neck and back pain and frankly I think they are very unattractive because they sag.
I nursed my child which made them sag alot more after she was born. Now I have never gone to the doctors for my neck and back pain. I have always just grinned and bared it.
Now my questions are:
Do I have to have a history of going to the doctors for my neck and back pain for my insurance company to consider paying for this procedure?
Should I start complaining about my neck and back pain now?
I have hesitated in the past because I assumed that all a doctor would do for these neck and back pains would be to prescribe pain meds, and I don’t do pain meds.
I would like to know if there are any words of wisdom out there from you guys on how I can go about getting this done, but unfortunately I can not afford to pay for “plastic surgery”. I can and would be willing to do this procedure in a heartbeat if I could have the Insurance Company pay for it.
Go to a plastic surgeon and get a consultation. (You will probably have to pay for this up front, but if your insurance does eventually okay the procedure, I think you can get reimbursed. Note: the consultation might be quite expensive - maybe a couple hundred bucks.) Also, you might need to get a referral from your primary care physician – check your health plan.
Tell the surgeon you are considering BR surgery and he will evaluate you: he will take pictures, take a history of any neck or back pain you are having, ask if you have red marks in your shoulders from your bra straps digging in, etc.) You can be quite up-front about telling him that you can’t have the surgery unless your insurance will pay for it. The doctor will submit a request to the insurance company and they will evaluate whether or not you have a medical need for surgery. This has to do with your history plus how large you are now, what you weigh, what bone structure you have, etc.
It can’t hurt to give it a try. I know several people who had insurance pay for it – it’s rather common. If it’s medically warranted, the doctor will want to help you get insurance to approve the charge.
Good luck! I don’t know one person who had the surgery who later regretted it. Most have said it was the best thing they ever did for themselves in their entire lives.
Okay. Generally speaking, breast reduction is plastic surgery, and plastic surgery is not covered under most insurance policies in the absence of disease or injury.
If you are, in fact, having back and neck problems from the weight of your breasts, this needs to be documented, as well as a recommendation from your physician that a reduction is the best course of action to fix the problem. This may take some convincing of your doctor that this is really the case, however. The insurance company may ask you to have a second opinion before they’ll cover the procedure. Basically, the more documentation you can show, the more likely the insurance company will be to cover the surgery. If nothing else, documentation will support you if you have to appeal a denial.
A friend of mine had her reduction paid for by the state (Arizona) about ten years ago as a medical neccessity. Her bra straps were cutting into her shoulders so badly that the nerve pressure was making her arms numb. She’s not on the SDMB but if you want I can put her in contact with you.
Plastic surgery is covered under many circumstances. It is “cosmetic surgery” - done solely to improve or change one’s appearance for no medical reason - that isn’t covered.
I know six people who have had this done and it was very easily approved by their insurance companies; obviously, after having them get evaluated by the plastic surgeon and possibly referred by their primary care physician. Not one of them had to fight about it and were in fact surprised by how (relatively) easy it was to get the procedure approved. Of course, it really was medically warranted for these people. If someone didn’t really need the operation I am sure they’d have a much harder time.
From what you describe, I’d say you might have a good chance.
As someone who worked in insurance for several years, I suggest you see your primary care physician first regardless. Request a referral to a cosmetic surgeon (both a referral from the PCP and a referral through the insurance company if required on your plan). Also read your policy, especially the “exclusions” section, to see if the specifics on when BR surgery is covered is spelled out for you. In every policy I ever worked with it was either spelled out in the policy or the company had a written internal document explaining the criteria. As long as the PCP and the cosmetic surgeon are both covered by your insurance you shouldn’t have to pay the costs of the consult up front (although you may have copays or coinsurances).