6 Steps to Speed Insurance Coverage for Breast Reduction

The process of seeking prior authorization for Breast Reduction can be very frustrating because many insurance carriers have developed more rigid guidelines prior to approval.  I have performed over 2,300 breast reduction cases, and my staff and I have developed a protocol that we have found very helpful in 1. Reducing the time for approval and 2. Increasing the percentage of those patients that have received approval for Breast Reduction. Below is our step-by-step approach to seeking prior insurance authorization:

  1. Seek your consultation with a surgeon that is board-certified by the American Society of Plastic Surgeons who has performed a high volume of breast reduction cases and is familiar with the process of insurance prior-authorization.
  2. Review your symptoms and voice those carefully to your Breast Surgeon.  The most common findings  associated with enlarged breasts are:
    • Bra Strap Irritation
    • Upper and lower back problems
    • Neck strain
    • Chest wall heaviness
    • A decrease in overall activity levels because of the above
    • Overall difficulties during your employment because of your breast size
  3. Provide a complete list of the conservative measures that you have employed over the past year to improve your symptoms and if possible the notes regarding your treatment plan.
    1. Physical therapy: massage, heat treatments for the back (noted from therapist)
    2. Chiropractic care (letter from physician)
    3. Medication for back soreness: Tylenol, muscle relaxers
    4. Special support garments employed
    5. Documentation from your primary care physician regarding your symptoms
  4. Match a reasonable weight relative to your height
  5. If you are over the age of 40 most insurance carrier’s require the findings of your last mammogram
  6. A complete coordination of the above findings and a detailed examination with photographs should be done by your examining surgeon.  A comprehensive letter seeking prior authorization would then be sent on your behalf to your insurance carrier.

If the above guidelines have been met, we see coverage within 2-6 weeks.  If there has been inadequate documentation provided, the approval process may require 4 to 8 weeks.   Depending on the insurance carrier and the physical examination findings, our approval rate over a 30 year period has been 70 to 85%. This LINK will take you to the forms that we recommend our patients complete prior to our their initial breast reduction consultation with us.   Stay Well




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