Help me build a case for breast-reduction surgery!

October 13, 2010 10:14 AM

Breast-reduction surgery has been my unreachable dream for nearly twenty years now. At long last, finally armed with half-decent insurance, I've reached the point where they haven't said yes yet, but they also haven't said no. But now, how to proceed?

Right now, they're asking for well-documented records of physical impairment and attempts at conservative treatment.

Unfortunately, coming from a family that employed the "grit your teeth and bear it" approach to medical care, I'm not very savvy or confident about navigating the healthcare area. Despite plenty of legitimate woes, there's no real paper trail.

The physical impairments include nonstop neck pain, nonstop shoulder pain, lower back pain, shoulder grooves, and slouching. In workplaces, I have actually burned them cooking and pinched them stacking boxes, they're just that unwieldy. They look ridiculous on me. But the last straw has been that during running, being so topheavy seems to pull everything off-center, even with an industrial-strength jog bra that feels like a vise. I really don't want to give up running, even though I am already so self-conscious that I'm only comfortable exercising after dark. The conventional treatment approaches I've taken have included free weights, back strengthening exercises, alignments, running with weights and a mountain of failed "miracle" bras (expensive, yes, miraculous, no.)

So it seems like I'm close, but I fear starting down a new (this time documented) path of "conservative treatments" will be time-consuming, expensive in its own right, and may still lead to denial at the end of the day from the insurance company. I've existed in this state for decades and am beyond ready for a reduction, sooner rather than later. What can I do to get the approval from the insurance company I need to make it happen?

(Anonymous because people I know IRL read here. Throwaway gmail: [e-mail])

posted by anonymous to health & fitness (11 answers total)

I would suggest calling your doctor and to ask what they suggest. Perhaps they can take your history and have that be the documentation of previous conservative treatment and impairment?
posted by zippy at 10:16 AM on October 13, 2010

My insurance company cleared me for surgery that sounds a lot like yours -- necessary for physical and emotional reasons, but frequently perceived as cosmetic (I mentioned it here -- message me and I'm more than happy to send you a link to my blog, which may or may not be relevant to you.)

All it took was a formal "diagnosis" from my doctor, which basically stated that the way my body is currently is not normal, that it "producing function problems and has had an effect on the patient's medical heath" and will continue to get worse, and that it "cannot be treated with [in my case] orthodontics and physical therapy alone".
posted by i_am_a_fiesta at 10:26 AM on October 13, 2010

You mention shoulder grooves, I think one key piece of documentation would be to have your doctor photograph them and include them with any other information. No personal experience, but I've heard that is a marker for whether the surgery is necessary rather than cosmetic. As long as you have a doctor who is willing to go to bat for you, it sounds like you've got a strong case.
posted by kaybdc at 10:34 AM on October 13, 2010

Have you been evaluated by a surgeon yet? You don't say. My insurance company approved me for the surgery after the surgeon sent topless photos of me (apparently a normal part of the process, and they took them neck-to-waist so my face didn't show). The surgeon wrote a report that included my history, which he only knew about because I told him.

Perhaps your GP would be willing to write up a report including the things that have been tried, as zippy suggests?
posted by not that girl at 10:36 AM on October 13, 2010

My first attempt at approval for breast reduction surgery was denied. I had to go through physical therapy and lose weight before they'd let me have a consult with a plastic surgeon. He took measurements, photographed the grooves in my shoulders, and wrote down my physical ailments (back pain, shoulder pain, numbness in my fingers and hands, persistent headaches) and they approved it.

If they deny you the first time, CONTEST IT. Don't back down! Prove that it's in their best financial interest to pay for this surgery now, rather than for your ongoing care due to lack of surgery later.
posted by elsietheeel at 10:51 AM on October 13, 2010

I had a breast reduction in August. It was covered by my insurance. I got a referral for a plastic surgeon from my primary care physician and set up a consultation. After the initial consultation, the surgeon's staff took care of all the approval paperwork with my insurance company. If possible, I would definitely recommend talking to a surgeon first and asking for their suggestions. They have been through this process hundreds of times before and generally know what the insurance company will need before they can say yes. If get denied at first KEEP TRYING. Appeal, appeal, appeal.

This surgery is the best thing I have ever done for myself. It has been life changing in the most amazingly positive way. Good luck and feel free to MeMail me if you have any questions.
posted by fancypants at 11:35 AM on October 13, 2010 [1 favorite]

Like others have said, my doctor basically handled that part of it for me. If you have consulted one who doesn't seem to do that, keep looking around for one who will. It'll save you money in the long run.
posted by scratch at 11:44 AM on October 13, 2010

This support forum for breast reduction surgery has been an amazing source of information for me through my process with this. Ask the ladies over there this same question, they are a fountain of knowledge.
posted by MaryDellamorte at 11:54 AM on October 13, 2010

Hi! I successfully annoyed the crap out of my insurer in order to get my breast reduction.

What I did:
See your primary care physician. Mention the back and neck pain. Point out the shoulder grooves. Say you would like a breast reduction if you could get insurance to cover it. Get a referral for a surgeon (mine was cosmetic, I don't know if other surgeons also work in this area).

Meet with the surgeon. You may have to pay for this visit, depending on how your insurance company does stuff with copays, referrals, etc.

The surgeon will take photos and decide if you're a good candidate for a breast reduction based on medical need (it sure sounds like you are!). Maybe it's because my insurance is kooky, but make sure to get physical photos in addition to digital ones. My surgeon's office had to mail the one Polaroid he took because the insurer wouldn't accept digital photos. It was awkward.

The surgeon will contact your insurance company to see if they'll cover surgery. If you're denied, keep calling. Have your PCP's office call. Ask if they'll cover physical therapy. I lucked out - my doctors had amazing administrative staff that were willing to make appeals for me as well. This is key. You will have administrative staff backing you up.

Fingers crossed, eventually your insurance company may give you a list of hoops you need to jump through. Mine were: get x-rays, wear a supportive bra and go to physical therapy. Insurance covered everything (well, I didn't try to get reimbursed for the bra). Sometimes they'll ask you to lose weight - this didn't happen to me though.

Jump jump jump! Physical therapy will feel amazing. Your physical therapists will be awesome and confirm that building up muscles will not fix your problems. I ended up calling my insurance company a few times to see if I'd gone for long enough.

Then you wait for approval.

It took awhile. Your patience will be tested. Just remember how much you want surgery and expect to spend more time on the phone.

MeMail me if you have any questions.
posted by giraffe at 12:12 PM on October 13, 2010

Justifying breast reduction surgery will require careful documentation in your chart by your doctor. So, when you go to your doctor, that needs to be the only problem you come in with, not just one item on a list.
posted by neuron at 4:47 PM on October 13, 2010

My experience was I met with a surgeon for two evaluation appointments (and also had topless photos taken--I had more people look at my breasts during that period than really at any other time in my life), and I talked about the shoulder pain and the bra strap grooves and so on. It seemed to go through without any problems. I figured this was just because I had good insurance, but I just asked my mom (whom I happen to be visiting, and who is a physician), and she said she thinks it has to do with how the surgeon fills out the paperwork.

So I am not sure how helpful that is, but I would guess that the suggestions above about trying different doctors/surgeons are good ones, if you get turned down the first time.

I will also echo that it is one of the best decisions I have ever made--I had it done when I was 21 (and still on my mom's insurance, which is why I don't know as many of the details, as I was poorly informed about insurance then and it was many years ago), and I am grateful every day.

Good luck!!!
posted by newrambler at 7:45 PM on October 13, 2010