Traditionally,
breast augmentation (augmentation mammaplasty) and breast reduction (reduction
mammaplasty) surgeries are defined by health insurers as cosmetic.
It’s a definition
that often puts patients at odds with health insurers. Payers have difficulty
deciding if breast enhancement or breast reduction cases are medically
necessary.
For example,
a doctor prescribes a breast reduction for Andrea, a five-foot one-inch,
135 pound, 32-year-old female. Her plastic surgeon recommends removing
500 grams of breast tissue from each breast. Is this breast reduction surgery
considered medically necessary and something that is covered under her
medical insurance plan?
According to
Dr. Skip Freedman, medical director at AllMed Healthcare Management, a
leading Independent Review Organization (IRO), Andrea should qualify for
the breast reduction treatment because of the following reasons:
- For several
years, she has complained of shoulder, back and neck pain, bra strap grooving
and intertrigo (eczema).
- She wears
a 34DD bra and attributes these symptoms to her breasts.
- She’s worn
support bras, taken non-steroidal anti-inflammatory drugs (NSAIDs) and
has had years of chiropractic treatments without alleviating her symptoms.
- She has symptoms
consistent with macromastia (excessively large breasts)
- Her doctor
notes that her complaints are typical for a macromastia diagnosis.
According to
the American Medical Association (AMA), when reconstructive surgery, such
as breast augmentation or reduction, is performed on an abnormal structure
of the body caused by disease, infection, congenital deformity, trauma
or tumors, the reconstructive surgery is considered medically necessary
and generally done to improve the body’s function.
Breast surgery,
rather than conservative treatment or weight loss, provides the best chance
for Andrea’s relief. Additionally, patients, like Andrea, who have congenital
breast deformity or who have experienced breast trauma, infection, tumors
or disease, may also qualify for breast augmentation or reduction when
it’s considered reconstructive.
These patients
might have Poland’s Disease or cancer, breast drooping caused by dramatic
weight loss due to gastric surgery, significant breast asymmetry, or have
had a mastectomy.
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