Everything You Need to Know to Get Your Breast Reduction Covered by Insurance

You want a breast reduction but you aren’t sure whether you can get your insurance to cover it…you’re not alone.

We’ve all been there. It’s easier than it seems…if you know the tricks of the trade. We’ll give you the skinny on the secrets!

This is the definitive guide to getting your breast reduction covered by insurance.

 

The Holy Grail of Insurance Companies

It may be a dumb name, but the Schnur Sliding Scale (SSS) is your ultimate friend (or ultimate foe) when it comes time for insurance companies to say “yay” or “nay”.

The Schnur Sliding Scale is a chart that you can use to see if you fit the criteria for a “medically necessary” breast reduction. If you can prove that your operation is medically necessary, it will be covered by insurance.

Visit this site to calculate if you fall within the 22nd percentile.

In our opinion, the SSS is outdated…it relies heavily on your BMI which does not take into account your frame, muscle mass, or body composition. Unfortunately, because of this, many women are denied coverage. It’s a real shame that insurance companies put women through this, but below you will find tips and tricks to work around the Schnur Sliding Scale.

 

What Most Insurance Companies Require

Obviously, all insurance plans are different. To figure out what yours requires, call in to whatever company covers you and ask.

However, there are a few requirements that are basically standard in making your case to your insurance agency.

1.     Most require you to demonstrate that you experience pain in at least two areas of your body for at least a year. Shoulders, back, abdomen…all count! Even numbness in arms. Fortunately, if you experience body dysmorphia or depression due to your breasts, this counts! You could also prove that you have had issues with the ointment or cream available for underboob rashes. This, unfortunately, requires you to keep proof of the severity and length of pain for a year that you are experiencing problems, which obviously prolongs the surgery date. But, believe me, it’s worth it.  

2.     While you wait, you should be taking pictures of your breasts and the physical manifestations of pain you experience from them. This will help you lobby your insurance company.

3.     You must also prove that you have attempted previous therapies. This includes anything from getting a properly fitting bra (ugh) to taking pain meds (real nice) to going to a chiropractor (so fun). You have to prove that you have tried for at least three months to get these things done. If these things sound expensive (they are), there are some surgeons out there that will meet with you and fulfill the requirements without you having to go and see a bunch of different specialists.

4.     Often, insurance companies will require you to be within 20 percent of your ideal body weight. Some women will be asked to lose weight before an insurance company will cover their reduction. This is a really tough one for some women as many women seek a breast reduction because exercise is so painful in the first place.

5.     Insurance companies will also require that your surgeon remove a certain amount of tissue from your breasts. This varies due to your weight and BMI, but most patients have to remove at a minimum 500 grams in order for your surgery to qualify as “medically necessary”. This lower floor is a roadblock for some women who are more petite as sometimes surgeons just can’t get 500 grams out of each breast. However, your doctor can prove that even if you can’t take 500 grams out of each breast, they are still proportionally too big for your body.

6.     To submit an application to your insurance company, you will need to present a surgeons note, a personal letter, pictures (of your breasts and of any physical signs of discomfort such as shoulder grooves or indentations from your bra straps) and notes from the plastic surgeon. You will also have to fill out a packet from your insurance company.

7.     You may have to wait to hear back anywhere from two to six weeks or even longer.

 

If You Get Denied

1.     Don’t freak out.

2.     Try again.

3.     Often, if you re-submit your request, there is a high chance that you will be approved on your second try. There are some insurance companies that always deny the first time hoping you won’t re-submit. Although there is no guarantee, there are tons of stories online from women who have successfully lobbied for a reassessment.

4.     Sometimes, your doctor will go above and beyond and step in for you. Sometimes, they will call into your insurance company themselves (instead of a medical biller) and plead your case. This is a great strategy in case you cannot fulfill the 500-gram rule. Your doctor can present evidence of all of the medical treatments you have gone through. Sometimes, they will approve it on the spot.

 

If the Surgeon you Meet Doesn’t Have your Back

1.     Get a second opinion.

2.     Everyone, with every medical issue, should get a second opinion. You are no different! If you don’t like your surgeon or if he tells you that your pain or experience doesn’t qualify you for a surgery, ditch him/her. He owes you nothing!

 

Good luck and email us at Meghan@jellymedical.com if you have any questions :) 

 

 

 

Meghan Fitzpatrick