Breast reduction is a procedure that, as its' name implies, reduces the size of breasts that are too large and too heavy. It is performed to relieve the severe back, neck and shoulder pain associated with large, heavy breasts. Ideally a woman will have this surgery before the weight of her breasts cause secondary changes in her spine, such as herniated discs, which cannot be reversed.
Breast reduction is seldom cosmetic because the goal is to relieve pain and it has a very high success rate, a position supported by extensive research and The American Society of Plastic Surgery. Given these facts, one might think that insurance companies would be sympathetic to the plight of this group of women who are living in pain. However, if you did entertain such a thought, you would be sadly mistaken. Breast reduction is the #1 plastic surgery procedure that is rejected by insurance companies.
Why would insurance companies deny approval for surgery? The answer is that any surgery successfully denied is an expense that never happens, and they make more money.
Why pick on breast reduction? That one is easy. This group of women are an easy target. Breast reduction does improve appearance so it can be, and often is, labeled as cosmetic. Most women are overweight, and insurance companies will allege that if the patient would lose weight the problem would go away. Enlarged breasts are not the only cause of back and neck pain, making it difficult to prove that heavy breasts are the cause.
Consider a conversation I had with a nurse at a medical management company in Indiana, whose job it is to approve or deny insurance claims for one of the school districts. I was responding to a letter denying approval for breast reduction for one of my patients.
The explanation in the letter was: "The documentation does not support conservative treatment was optimized." This was in spite of a letter I sent documenting that this patient had been taking pain medicine for two years and had also had physical therapy. Here is how it went, not word for word, but very close.
"I received your letter but there was no information on what this patient could have done, or didn't do, that caused this denial. How are we to know what she needs to do to obtain approval if you don't tell us."
"That's not our policy."
"Then how are we supposed to find out?"
"You could try conversation."
"I thought that was what we were having. So you can tell me now."
"How do we know that this is the cause of her back pain. There are lots of causes of back pain. And she should see a therapist or a chiropractor for her pain."
"But I told you that she saw a therapist and didn't improve."
"How do we know she saw the therapist for back pain. People go to therapists for lots of reasons."
At that point I knew I was in a virtual "rat's maze" and there was no way out. I asked to speak with the medical director and I have a phone appointment with him next week. I guess this type of work keeps them very busy.
Everything in insurance is ultimately a "numbers game" and this is no exception. What I described is a typical set of roadblocks thrown in front of a patient. The insurance companies do allow for appeals, and second appeals, and third appeals. Unfortunately, most patients either become exhausted or do not have the knowledge (since so much of it is withheld) to navigate the system. They simply give up, and that is how the "numbers game" works. If ten patients are denied breast reduction and only two take it to the third appeal, even if they are successful the insurance has a savings of 80%. Who can blame them. They have a responsibility to their shareholders, and no one ever died from heavy breasts.
The systematic denial of breast reduction surgery is a symptom of a much larger problem: the incentive each insurance company has to withhold care. The solution is to change the system so the incentives do not work against the patient, against you. Politics being what it is, it is hard to imagine a solution that will not favor the insurance industry and their well-paid lobbyists. In the meantime, I am left to helping my patients overcome this abuse, one battle at a time.