Breast Reduction - No Coverage for All?
When we think of breast surgery, we generally think of breast enhancement first. We imagine Hollywood wives getting implants as casually as many women get their eyebrows waxed. What we don't generally think of is breast reduction surgery, and if we do happen to have it cross our minds, we probably assume it's another vanity procedure.
For some women, that may be true. For thousands of other women, however, the size of their breasts is a serious health issue, causing serious pain in their shoulders, in their backs - even to the point of spine curvature - and in some cases limiting their ability to participate in activities that would otherwise benefit their health and well-being.
No problem, a woman dealing with such issues might think. After all, breast reduction is covered by insurance, isn't it? Tragically, in many cases the $5-7,000 procedure is not covered. Even more tragically, there are no real standards to determine when it is, and when it isn't.
What the Numbers Say
Recent studies have helped many plastic and reconstructive surgeons realize the insurance coverage policies are both arbitrary and unfair. For example, in the September 15th, 2007 issue of Plastic and Reconstructive Surgery, a published study shows that most insurance carriers will not cover breast reduction unless at least 500 grams of tissue per breast are removed, leaving many women who would benefit from the surgery out in the financial cold.
According to the study, the biggest problem is that insurance carriers often don't review all the factors involved in each case. They look only at how much tissue will be excised, and not at the whole woman. By doing this, women with compact builds and small body frames may be excluded, even if their breasts are proportionally too large for their bodies, and cause them significant back and shoulder pain. Smaller-framed women, the insurance industry says, typically seek breast reduction for cosmetic purposes, and not health-related ones.
A Not-So-New Hope?
Of course, other studies contradict the theory that not seeing the big picture is the crux of the insurance problem. Last year, for example, Reduction Mammaplasty: a Review of Managed Care Medical Policy Coverage Criteria presented results which pointed to the need for a drastic overhaul in the coverage policies. Specifically, in eighty-seven different health insurance plans, the criteria for breast reduction coverage were compared to medical guidelines for the procedure. Not one plan entirely supported the medical literature, and many of the policies were found to have no basis in scientific data whatsoever.
Described in the 2006 presentation were "invalid guidelines" that the insurance industry uses to determine coverage, which include minimum age, maximum body weight, volume of tissue to be removed, and whether or not non-surgical treatment was attempted. The guidelines in question were in almost every managed-care plan, causing much concern among surgeons and patients alike.
Still, the fact that studies are being done does give some hope that as patients and their doctors continue to document treatment attempts and challenge their insurance companies, coverage policies will change, and women who need breast reduction to improve their health will have insurance to pay for it.
