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Do I need my Primary Care Physician's recommendation to get approval for breast reduction surgery?

Q:

I am 24 years old and my breasts are a size D, most likely larger.  I want to have breast reduction surgery as my breasts are causing me neck, back and rib problems.  I have insurance through the state and I'm  not sure if they will approve the surgery.  Do I need my primary care physician's recommendation to get approval from my insurance company for the breast reduction surgery?  Since my breasts are causing me pain, do you believe that the state insurance will cover this surgery?

A:

Hi Jessica, Thanks for your question!

Although your insurance is through the state, unless it is an HMO, there is usually no need to have your primary care physician provide a recommendation.  Most insurances (state-issued included) will consider surgeries as long as they are medically necessary.  You state you are seeking the reduction due to neck, back and rib problems and if this is affecting your daily life and hindering you from working, then your insurance will take this into consideration when providing coverage for the surgery.  This being said, it would not hurt for your primary care physician to provide any medical documentation they may have, which may help your insurance company better understand the need for the surgery.

To clarify, I am a board certified plastic surgeon who specializes in cosmetic breast augmentation, including all newer aspects of the short scar procedures. I'm also a proud member of both the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS).  I am board certified with the American Board of Plastic Surgery.  I am also an active member of the American College of Surgeons. I believe that each patient needs to be treated as an individual and we focus on listening. Obviously, I would need to examine you and help you to decide which surgical or non-surgical options are available in your particular case.

If you have any further questions, please feel free to call us at 847.696.9900 for a private consultation. We would also be happy to mail you some additional information and brochures.  In case you have not done so yet, please check out our website at www.prplastic.com for a wealth of additional information as well as a lot of before and after pictures. Thanks for your question. Have a great day!

Best regards, Dr. Speron 

A:

With the symptoms you have, if you need enough breast tissue removed to meet your insurance company's requirements for breast reduction, you may not need your primary care physician's recommendation.  However, having a recommendation always helps, as insurance companies are always trying to find some way to deny breast reduction.  If he/she is willing to write you a letter, by all means have it done and sent with the pre-certification letter from your surgeon.

A:

The requirements for insurance approval and coverage of breast reduction surgery varies widely from carrier to carrier.  

Requirements may include:

  1. Photos of your breasts
  2. Letters from your internist documenting medical problems such as neck and back pain,
  3. Trial of physical therapy
  4. Minimum amount of breast tissue to be removed by the surgery
  5. Letters documenting these steps from each physician and surgeon

You should seek a consultation and guidance with these steps from a board certified plastic surgeon in you area.

Fredrick A. Valauri, M.D. F.A.C.S.M.D., F.A.C.S. - View Other Answers by this Doctor
New York, NY

A:

As my colleagues have already stated, reduction surgery is covered by insurance if deemed to be medically necessary.  Criteria as to what constitutes "medically necessary" vary by insurance programs.  I would suggest contacting some surgeon's offices and see if you can schedule an appointment without a referral.  Most offices will let you know when they find out the details of your insurance.  A consultation would then determine if you would meet the criteria for a medically necessary reduction.

A side note... if you're dead set on wanting to breast feed should you have children, I would advise waiting until you are done with childbearing.  Reductions will diminish and can sometimes prevent you from breast feeding in the future.

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