Bulletin Board for Patient's Questions and Answers

Breast Reduction (Reduction Mammoplasty)Insurance Refusal Letter

Breast reduction insurance issues have resulted in many emails to Dr. Bermant.

Michael Bermant, MD
Board Certified by the American Board of Plastic Surgery

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Many readers have sent email asking us to write a letter to help with insurance company refusal for coverage for breast reductions planned by other doctors. I am sorry, that is best from a doctor who has examined the problem. There is no magic in such letter writing. The truth about that patient's problems is the best answer. Each insurance company has their own criteria (to approve / deny / refuse to cover surgery) and review process. Not all patients have all of the problems that others suffer. The following letter was sent to me from another doctor's patient demonstrating one case of someone who, after having been turned down for breast reduction, was finally approved. This case sounds like one of a massive breast reduction and probably should have been approved the first time not needing reviews.

Dr. Mike: I would be honored! I sent an e-mail you and some others, with an attachment of the sample letter, altered to omit my personal information. I was a fairly large reduction case, my PS removed just over 6 pounds of tissue. He did a traditional anchor incision, and although I was extremely large, kept my nipples and nerves intact using the pediale method. I went from a size 40 I (II) down to about a 42 D. I am very satisfied with the results. The information I gained from the board

[breast reduction on America Online (aol://5863:126/mB:108465)]

has made all the difference. You were also helpful with some questions I had one night when you attended our weekly chats session. Please use my letter, or comments, however you see fit!

M

When I wrote the letter, I had been denied surgery, and in order to appeal, I needed to submit a letter stating why I wanted them to reconsider their decision. I asked my PS and my GP to also write letters on my behalf, and they gladly did so. I wanted the letter to be businesslike and professional, as well as provide a strong impact on the reader. I felt that it did the job.

To Whom It May Concern:

I am in dire need of Breast Reduction Surgery. I endure extreme pain due to my abnormally oversized breasts. My breasts are so large that it is difficult for me to participate in everyday activities. Bilateral reduction mammoplasty is medically necessary in my case, for several reasons.

I have chronic pain in my neck, shoulders, upper and mid-back. Throughout the years this heavy weight has caused my shoulders and upper back to curve forward, leading to misalignment throughout my spinal column. Diagnosed with Sciatica, I am currently taking prescription Ibuprofen for my constant pain. Every time my leg goes numb and I lose all feeling, I worry about the long-term damage to my nerves. I also feel uncomfortable about continued use of prescription painkillers and the affects of non-steroidal, anti-inflammatories on liver tissue.

In addition to this lower back condition, I also suffer from pain in my middle and upper back, shoulders, neck, and arms. At times, I can feel nerves being pinched in my upper back and neck area, and jolts of pain will radiate down my upper extremities. The weight of my breasts is a strain on all these areas, and the pains are increasing steadily. My back crackles and pops each time I try to straighten out my hunched forward shoulders.

I am frightened about the obvious and continued misalignment of my spine, and I worry about suffering permanent damage. I am desperately trying to lose weight to relieve this debilitating pain, and avoid future back surgery. Unfortunately, my breast size greatly interferes with my ability to exercise.

It would be much easier to achieve my weight loss and fitness goals, if I were able to exercise freely, and without pain. I have always had trouble breathing properly while exercising. Even as a young teenager, my family doctor admitted that the extra weight on my chest would always make it harder for me to breathe.

I am enrolled in a weight resistance program at the fitness center I joined. The Chest machine, a basic piece of nautilus equipment designed to strengthen pectoral muscles, is difficult for me to use correctly. My abnormally large bust makes it impossible to fully complete the range of motion, which contracts the targeted pectoral muscles. This is very frustrating, since it is the best way to build chest muscle support for the load I carry.

Horseback riding is one of my greatest loves, but it wrecks havoc on my body. The jostling causes my breasts to flop around, despite my best attempts to secure them with supportive attire. There are several other sports I would love to try, but I find it nearly impossible to move freely and without embarrassment since I cannot control the bouncing of my massive breast tissue.

My bra has ultimately become an instrument of pain as the bra straps cut into my shoulders. I have permanent grooves in my shoulders where the bra straps have exerted their pull. I will always have these scars as the bone has been permanently molded. A reduction will not make this go away. But it will lessen the pull, and cause less pain and disfigurement in the future.

Even with the best of bra support, there is still some overlap and contact between my breast skin and my lower chest wall skin. Especially in the summer, I always have a chronic skin irritation. During exercising, it becomes very sweaty, and irritated, due to moisture accumulation and chafing.

Another factor in my decision to seek a breast reduction is the fact that breast cancer runs in my family. My aunt and two maternal great aunts, all had breast cancer. It is virtually impossible for me to do an accurate self-examination, as my large breasts are very dense. I understand that early detection is my best weapon against breast cancer, but I may not be able to detect something that is located in an area that I cannot feel. I am very concerned about my inability to conduct a breast self-examination successfully.

Although I have not yet experienced a mammogram, but I understand it is a much more painful procedure with large breasts than with smaller ones. And a mammogram may not give an accurate reading either, as the breast tissue is very thick and it is difficult to see through.

I am quite self-conscious about my breast size. I know this is not something that is normally evaluated. However, I want you to know how I feel as a whole. I have suffered a variety of unwanted attention for many years. It is hard to find clothes that fit around the bust, and increasingly difficult to locate bras. I wear a size 40 I.

Even after losing nearly 35 pounds, my bra cup size has not decreased. In fact, if I could actually find a bra with a larger cup size, I would order one. I don't fit neatly into my current bra cup size. I constantly need to readjust my bra, so that my breasts are not bulging out in front and showing a big ridge. I do this "shifting" of my breasts in the bathroom, or in my office at least 10-12 times each day. I always wear two bras in order to support the weight of my breasts. I never undress in front of anyone, not even my sisters, because of the humiliation of having to wear two bras, one on top of the other.

Thank you for taking the time to read my letter. I wanted to express my concerns and outline the reasons why I need this procedure. It is my goal to be healthy and active. I believe with this surgery, I can finally reach that goal.

Due to the extreme abnormality of my breast size, breast reduction surgery is most definitely medically necessary. Please review the enclosed letters of support from my Primary Care Physician, and Plastic & Reconstructive Surgeon.

I hope you will reconsider this important decision.

Sincerely,

xxxx

Enclosed:

• Original Letter requesting authorization (11/5/XX, Doctor's Name, MD)
• Denial of Authorization
• Letter of support from PCP (Doctor's Name, MD)
• Letter of support from Plastic Surgeon (Doctor's Name, MD)

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