Will Insurance Pay for My Breast Reduction?
Insurance companies try very hard not to pay you for your breast reduction surgery. They say it is a cosmetic plastic surgery unless confronted with negative health sequalae.
They will ask you to lose weight, have physical therapy for the neck and back pain and have the surgery pre-approved before allowing you to undergo it. On top of it all, they will not tell you what they will pay toward your surgery!
Each insurance company has its own criteria, and these criteria change based on the specific plan you have with them. All, however, require certain conditions based on your height, weight, body surface area, BMI, etc. to be filled before you are considered for the surgery.
Letter for breast reduction
Here is the typical letter that your cosmetic plastic surgeon needs to write for patients who are considering breast reduction so that they can get approved by their insurance for a reimbursement of their surgery costs. The typical codes for diagnosis (ICD9) and the procedure codes (CPT) are included.
Dear Medical Director, I am writing to you at this time to obtain authorization for coverage of breast reduction services for your insured, and my patient, Mrs. X
Mrs. X is a female in good health who complains of enlarged breasts. She feels the weight of the breasts when she exercises and this prevents her from maintaining a healthy lifestyle. In the past she has suffered from pain in her shoulder, upper back and neck due to the size of her breasts. She also complains of intertrigo, (chaffing of skin under the breasts).
At this time she requests breast reduction surgery to alleviate these symptoms which are causing functional problems for her.
My history and physical exam as well as photographs are attached.
I have discussed the options that are available for her treatment. She understands the procedure of breast reduction which will be a vertical mammoplasty. The scars that will remain after the surgery have been explained to her. I anticipate removal of at least 350 grams of tissue from each side. This amount falls within the 22% limit for patients of an even larger frame than this patient as per the Metropolitan life insurance tables. The risks and complications including nipple necrosis and numbness of the breasts have been explained to the patient and agreed to by her. The advantages to this procedure over the traditional mammoplasty have been explained to the patient. They include significantly less scarring of the breast than the Wise Pattern technique which is associated with more pain.
The large size of her breasts along with the pains in her neck, upper back, back and shoulders, as well as the interference with her activities of daily living are further points to be considered. She has already undergone non surgical treatments including weight loss, exercise treatments, pain medications, supportive bras to no avail. Surgery will be set at Woodburn Inova Woodburn Surgery Center on an outpatient basis.
The ICD9 codes for this surgery are 611.1, 695.89, 719.41, 723.1, 724.1, 724.2.
The CPT codes for this surgery are 19318 and 19318.50.
I would appreciate hearing from you at your earliest convenience regarding the authorization for this surgery. Please contact me if you wish to have any further information.
Morad Tavallali, M.D., FACS
For more breast reduction information, start here: Breast reduction