Breast reduction surgery presents an interesting issue when we're getting into an era where every health care cost is going to be scrutinized. As a society, is this a procedure we're going to be willing to commit major funding to? Currently there is a patchwork of indications that vary between different insurance companies as to what meets medical necessity for this operation.
In general, most insurers make you do extensive documentation of "conservative therapy" before even considering approval. I'm not sure what conservative management of big breast is exactly anyway! There are differing weight requirements for the tissue to be removed as well. Blue Cross of Alabama for instance requires a minimum of 500 grams (~1.1 lbs) per breast to be removed. Others use a sliding scale called the "Schnur Scale" to correlate appropriate weight removal to a calculation of your total body surface area (TBSA). The Schnur scale came from a paper by a plastic surgeon who was trying to quantify symptoms in his breast reduction patients.
The recommendations from that study by Dr. Schnur were perverted by insurers, written into policy guidelines, and are now used to exclude many patients from having breast reduction surgery. There now exists a great deal of literature showing that reductions much less then prescribed by insurance companies is effective in patients suffering from neck, back, and shoulder pain. In fact, a Finnish study suggests breast reduction surgery seems to improve the health-related quality of life indicators as much or more then surgeries for hip or knee joint replacement.These studies are dismissed by insurers as observational,flawed, or biased by greedy doctors, but if they could speak honestly they would explain that they don't want to open eligibility for the procedure to a whole new class of patients and cost themselves a great deal of money.
Apparently we're not the only country that is having issues on whether to cover breast reduction surgery. Hat tip!
A court in the German state of Hessen has ruled that insurance companies do not need to cover the cost of breast reduction surgery as having a large bust is not a medical problem. The decision means that insurers will only have to pay to correct breasts which are deformed.
The case was brought by a 38-year-old woman who suffered orthopaedic and physical problems due to the weight of her boobs. She had been advised by doctors to have breast reduction surgery.
But her insurance company didn’t see it as a necessity and therefore refused to cover the costs of the operation. It claimed she was suffering from back problems because she was overweight and that her physical discomforts would be reduced if she trimmed down weight and built some muscle up.
The court agreed with the insurance company and the big-breasted woman lost her case.
Two and a half years ago, the court in Hessen rejected the case of a woman who thought her breasts were too small. She wanted her medical insurance to cover a breast enlargement operation and claimed that she was physically harassed for her small boobs. The court declared then that small breasts are not an illness
Rob
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4 comments:
Last year I went from a DDD to a large B/small C cup thanks to a reduction surgery (I'm 5'2" and weigh 130. DDD for me was huge). I was lucky, my insurance company approved the procedure without too much of a fight (My PCM went to bat for me with them), but I have heard horror stories from women who are suffering with awful back, neck and shoulder pain every day because their insurance companies won't approve a reduction for them, stating that it's a cosmetic surgery. It's silly, really...people get rhinoplasty surgery approved for non-cosmetic reasons, so why should a breast reduction be any different?
Dear Dr. Oliver,
Boy, are you right on! In my plastic surgery practice in Ventura, California, breast reductions are the most appreciated surgery by far. Many big-busted patients have terrible pain; many have had neck surgeries, shoulder arthroscopies, chiropractic manipulations, etc. Yet, it is only after standard breast reductions that they finally gain relief.
With Obamacare on the way, breast reductions are procedures that we Board Certified Plastic Surgeons should fight for. Our president wants scientific evidence that various medical procedures work. I could give him gobs of data!
Thanks for the great site--informative, well-written, and frequently hilarious!
Sincerely,
Michael C. Pickart, M.D., F.A.C.S.
I agree, it is ridiculous that a lot of insurance companies do not consider breast reduction as a medical procedure v/s a cosmetic procedure. My insurance won't cover any type of preventative care. Without a lot of saving or a lot of change in medical coverage, this procedure may not be available for majority whom really need it. We definitely need a change.
It's my understanding that in Canada, the government health care program will pay for breast reduction in many cases.
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