How can I fail physical therapy and get my breast reduction covered?
June 20, 2011 8:05 AM   Subscribe

I'm trying to get approved for breast reduction surgery and my insurance company says that I need to fail 6 months of physical therapy. I didn't realize PT is pass/fail..?

I'm in the beginning stages of getting the ball rolling for breast reduction surgery. I'm 25 yo, 4'11", 100 lbs and I wear a 28E/F or 30E/F. I'd like to get down to B or a small C. The main reason I want the surgery is superficial: I feel like a bimbo and like my breasts don't fit my frame at all. It's really hard to find bras, bathing suits, and sports bras that fit me. My breasts also get in the way of exercising. I like to run and lift weights but my breasts hurt my neck like hell when I do so. I've tried many different kinds of sports bras.

I told my regular doctor at my last checkup that I wanted to get the ball rolling for a BR. Her receptionist got back to me and said that my insurance (blue cross blue shield) said that they wouldn't cover a surgery unless I failed 6 months of physical therapy.

I made an appointment with a PT place, but I don't know what to expect. How would I "fail" physical therapy? My breasts aren't enough of a burden that they cause me physical pain in everyday activity, just exercising. What kind of tests are they going to do, and what can I do to better my chances of my insurance company covering my surgery?

small print - I'm not interested in bra recommendations or big-bust bathing suit companys; I've spent a small fortune in bathing suit tops and sports bras from bravissimo and fig leaves and frog bras from title 9. I want this surgery and I won't be able to have it unless it's covered my insurance.
posted by anonymous to Home & Garden (12 answers total) 2 users marked this as a favorite
Speaking directly with your insurance company will probably give you a fuller answer of what documentation they need on their end in order to approve coverage.
posted by SomeTrickPony at 8:11 AM on June 20, 2011 [1 favorite]

I'm also covered by BCBS, and I've been doing PT for RSI that had gone so far as to lock up my neck and shoulders. YMMV and all those other disclaimers. The way it worked for me is an initial evaluation where the PT had me do a bunch of movements and took measurements of my range of motion, etc. Then she set a course for my recovery that included massage twice a week (covered by insurance, heaven!) and all these other processes like traction and prescribed stretches for several months until everything unlocked enough to start doing intense exercises during therapy and on my own to work those areas specifically.

BCBS has my PT reevaluate me periodically to see if I've resolved the issue, and has continued to cover the costs based on her recommendation. I have a wonderful PT who is very sensitive to what I ultimately want (to get better of course, but also to train myself to work in a way that doesn't reestablish the injury once I'm finished with PT), and she continues to be generous in her reevaluation, and not pushing me to "graduate" before I'm fully recovered. I've been surprised by how much therapy has helped me overall, especially in regard to posture and better body alignment for movement.

All the PTs I've worked with so far have been great patient advocates. If I were in your shoes, I'd tell the PT your story, explaining that you need to have 6 months before you can have the BR. Emphasize your pain exercising. Don't downplay any other potential symptoms - headaches, bad posture? They will work with you for the allotted time period trying to find solutions to that issue. You might be surprised to find it's generally useful. After 6 months, the PT will reevaluate you and make a recommendation to insurance about your progress. That's how I understand it to work in my case.
posted by mmmcmmm at 8:38 AM on June 20, 2011 [1 favorite]

Most insurances will consider covering a breast reduction only if the size of your breasts is causing pain, lack of mobility, etc. If they are not causing those kinds of problems, or if your problems can be treated with PT, then they will consider the reduction cosmetic.

If they cause pain during exercise only, that's something you would discuss with your therapist in order to create a PT regimen. As to what the guidelines are on the insurance side, only your insurance can tell you that. They write the policies and guidelines not just for their particular company, but even for individual groups. Your PT office can also give you some guidance based on past experience with other patients, but a call to your insurance company should be your first step. Make sure to tell your therapist about any issues/discomfort you may be experiencing, regardless of whether you think it might not be directly related to your breasts - you never know what will be related, and it will help bolster your case.
posted by DrGirlfriend at 8:42 AM on June 20, 2011 [1 favorite]

Could you get a referral to a doctor or surgeon who has experience specific to breast reduction surgery (and insurance coverage)? This is a specialized area for insurance approval and from my anecdotal understanding a lot depends upon having a savvy insider to help you jump through the hoops.
posted by ClaudiaCenter at 8:47 AM on June 20, 2011 [1 favorite]

My guess is that you will get further if you have actual pain issues from your breasts. Insurance is unlikely to cover "I feel like a bimbo" pain just as they are unlikely to cover "I want to feel like a bimbo" breast enhancement. I'm really surprised you haven't had any pain. I have a slightly larger frame and DD boobs and they have definitely caused me neck and shoulder pain. I think I'd have better posture with smaller boobs.

You might concurrently look at privately financing the endeavor. There are probably financing options and it certainly looks like a quality of life issue.

If I were getting it done, I'd go for a full B. A friend got hers reduced to a C and they grew a bit. She's not as big as she was but she was a little disappointed.
posted by amanda at 8:50 AM on June 20, 2011

I have to fill out a form at every PT appointment saying what percentage improvement from when I started treatment I've experienced, and I have to detail things like what's improving me and how long the improvement lasts. (I've been going for pregnancy back pain ... the massage and exercises they do work for about two days, then I start locking up again.) Based on the level of improvement and how long the improvement lasts, my insurance will pay for more frequent visits, or more serious treatments, or whatever. Obviously I don't need more serious treatment, I just need to get to the finish line here. But I discussed with the PT manager whether I wanted to come 3 times a week because my lack of improvement was well within the guidelines for my insurer to up me from 2 to 3 times a week.

(I didn't want to, I'm so tired of going to doctors!)

Anyway, if you have back pain and neck pain and so on from big breasts, I'd think this is unlikely to permanently improve with PT. Definitely get more info from the insurer and/or the PT place.
posted by Eyebrows McGee at 9:14 AM on June 20, 2011

My breasts aren't enough of a burden that they cause me physical pain in everyday activity, just exercising

I think you're spinning this the wrong way if you want to encourage your insurance company to cover it. Though it's unfortunately not true for most people, exercise should be a part of "everyday activity." This is clearly recognized by health authorities and agencies and experts around the world. Does your BCBS plan provide some reimbursement for gym memberships if you go a certain number of times each month? That indicates that they recognize the importance of regular exercse. If your breast size makes it painful to work out, you will miss out on the myriad health benefits of exercise, potentially leading to bigger health problems down the road.

Don't minimize (heh) the problems you're encountering due to your stature. Not being able to exercise comfortably is a problem worth dealing with.
posted by vytae at 9:16 AM on June 20, 2011 [14 favorites]

at your age the problem is only going to get worse and at a later stage the mastalgia will be added to the other mechanical aches and pains from the weight imbalance.

I would say you should think long and hard (& talk to someone who knows you really well) about how you move, what odd aches & pains you have regularly that is different for you than others. Because you're accustomed to living like this you think a lot of things are normal.

Off the top of my head, tight shoulders leading to stress headaches, hunched posture leading to achy lower back pain, hormonal monthly breast aches.....

Ask an OB GYN if you are at risk while pregnant to developing gigantomastia (family history is important here)
posted by Wilder at 9:56 AM on June 20, 2011 [2 favorites]

Plainly put, you're going to have to lie. Do some research online, see what sort of aches and pains people complain about when they have large breasts that cause them trouble. I had neck pain, shoulder pain, numbness and tingling in my fingertips, and any sort of exercise caused me pain because I couldn't find a decent sports bra that stopped the bouncing. I had minor divots in my shoulders, but the day I went to have the photos taken for the insurance company, I wore my bra straps cinched down tight as well as a bra with too big of a band so they looked worse than they usually were.

I also had to "fail" PT with mine. Basically you go, you tell them your imaginary aches and pains, you do what they tell you to do in and out of PT, then during the course of it and at the end of it you tell them that you don't feel any improvement. Ta da, you've failed.

Good luck, breast reduction is one of the best things I ever did for myself.
posted by elsietheeel at 11:48 AM on June 20, 2011

I successfully had a breast reduction covered by my insurance company. You already have some great advice here, especially mmmcmmm's point that the physical therapist you see will likely have your best interests in mind.

Things to expect from physical therapy: laying down on a foam roller for exercises (it feels so good), back massages and exercises using a resistance band. They'll also give you some exercises to do at home.

It's entirely likely that you have pain and/or extremely tense muscles but you've grown used to it.

Memail if there's anything you want me to elaborate on.
posted by giraffe at 11:54 AM on June 20, 2011

My breasts also get in the way of exercising. I like to run and lift weights but my breasts hurt my neck like hell when I do so.

This is not a superficial reason to want surgery. You'd probably have a much easier time if you set aside the idea that your reasons for wanting it are superficial or trivial. Your breasts are large enough that they cause you pain and restrict your ability to move and exercise. Don't tell your doctors that you want it because you're vain (because you aren't being vain), tell them that you want it because your breasts are restricting your ability to do something that's both an ordinary part of everyday life and essential for ongoing health.
posted by Lexica at 1:39 PM on June 20, 2011 [3 favorites]

I had breast reduction surgery back in the fall and my insurance wouldn't cover it unless I jumped through a millon hoops. I decided to pay for the surgery myself. I got financing through Capital One Care Credit and then put the remaining balance on a credit card and I do not regret this decision at all. Getting the surgery was the best thing I've ever done for myself and it completely changed my life. There are other options if your insurance company doesn't budge.
posted by MaryDellamorte at 4:02 PM on June 20, 2011

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