Insurance Companies Deny Medically Necessary Breast Reductions Based On Random, Unproven Criteria

Main Category: Cosmetic Medicine / Plastic Surgery
Article Date: 11 Oct 2006 - 1:00 PDT

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What if you couldn't perform daily activities, such as exercising or running with your children, because of overly large breasts that caused unending pain? Despite existing scientific studies that outline the medical necessity for breast reduction, many insurance companies are denying thousands of women the procedure each year because of rigid, unfounded conditions to secure coverage, according to a study presented at the American Society of Plastic Surgeons (ASPS) Plastic Surgery 2006 conference in San Francisco.

"People often think breast reduction is an elective cosmetic procedure, but the majority of women seeking this surgery are legitimately debilitated by their breasts," said Michael Wheatley, MD, ASPS Member Surgeon and paper co-author. "The criteria most insurance companies use is not supported by medical literature and eliminates a large number of women from coverage, forcing them to fend for themselves." <

Most insurance companies require patients to exhibit specific signs and symptoms prior to approving breast reduction as medically necessary. The amount of tissue removed to relieve symptoms associated with overly large breasts is the most controversial of all insurance criteria.

The authors reviewed the breast reduction policies of 87 health insurance companies. Despite contrary medical studies, 85 companies require a minimum amount of tissue to be removed to cover the procedure - 49 of these companies require a minimum amount to be removed independent of the patient's height and weight.

According to published studies, although most patients have a one-and-a-half to two cup size reduction, the amount of tissue removed, body weight, level of obesity, or bra cup size do not affect the benefits that patients receive from breast reduction.

Many insurance companies require that patients exhibit all of the following symptoms to receive coverage for breast reduction: back, neck, shoulder, and arm pain; rashes; bra strap grooves; and numbness in the upper torso. The authors found that while most patients suffer from many of these symptoms, rarely do they exhibit all.

According to Dr. Wheatley, most patients are women between 30 and 50 years old who have had upper skeletal pain for years. Many of them have tried various treatments, including physical therapy and pain medications, to manage the pain before turning to breast reduction. However, many of these women are still turned away by their insurance companies.

According to ASPS statistics, more than 114,000 breast reductions were performed in 2005.

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For referrals to ASPS Member Surgeons certified by the American Board of Plastic Surgery visit http://www.plasticsurgery.org/ where you can also learn more about cosmetic and reconstructive plastic surgery.

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. With more than 6,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

Note: The study "Reduction Mammoplasty: A Review of Managed Care Medical Policy Criteria" was presented Sunday, Oct. 8 at the Moscone Convention Center, San Francisco.

Contact: LaSandra Cooper
American Society of Plastic Surgeons

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