Is Weight a Factor in Breast Reduction Insurance Coverage?

 scale w braIt is common for insurance companies to require a certain amount of breast tissue be removed from each breast in order for  the breast reduction  to be considered a medically necessary procedure covered by insurance. The proposed amount or weight of breast tissue to be removed is determined based on your height and weight. Often this weight requirement is in conflict with a woman’s aesthetic goals. Insurance companies are less concerned with the way you look. Yet physical appearance after breast reduction surgery can have an impact on quality of life regardless of the weight of breast tissue removed. Breast reduction procedures are often performed as an elective procedure without insurance coverage. Patients choosing elective cosmetic breast reduction have control of the volume of breast tissue removed. They report a high degree of satisfaction as a result.

Dr. Paul Schnur, a Mayo Clinic affiliated plastic surgeon, in 1991 developed the sliding scale from a survey that asked plastic surgeons. Years later, he challenged insurance carriers’ use of the scale and indicated that the scale may no longer be useful criteria for insurance coverage.

Each person responds differently to the physical symptoms of having large breasts. Breast reduction should be considered within the context of each individual woman’s quality of life. If you disagree with your insurance carrier’s decision, you are entitled to multiple levels of appeal of which you should take advantage. Letters from a family doctor, physical therapist, chiropractor, or massage therapist can help support an appeal. You should write your own letter describing your physical symptoms and how they have limited your quality of life. Ask your plastic surgeon to submit your personal letter, supporting letters and a list of medical literature references with the appeal.  

Despite medical literature proving that breast reduction surgery improves a woman’s quality of life regardless of the weight of breast tissue removed, a recent report by Koltz, Frey and Langstein (Plastic and Reconstructive Surgery Journal, 2013) revealed that 86 percent of surveyed insurance providers still use a chart based on the 1991 Schnur Sliding Scale that compares a woman’s motivation for breast reduction surgery and her weight.

Paul Schnur is a plastic surgeon affiliated with the Mayo Clinic in Scottsdale, Arizona. In 1991 he developed a sliding scale from a survey that asked plastic surgeons their perceptions of whether their patients’ motivations for a breast reduction were reconstructive or cosmetic (Annals of Plastic Surgery, 1991). Years later, Schnur himself challenged insurance carriers’ misuse of the scale and indicated that the scale should no longer be used as criteria for insurance coverage (Annals of Plastic Surgery, 1999). However, many insurance companies still use this sliding scale as a way to deny coverage for a breast reduction procedure.

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