How insurance paid

If you’re reading this, you’re either considering breast reduction surgery(bilateral reduction mammoplasty, as it’s called by the surgical team) or you’ve already had it and you’re looking for helpful information to see if you’re experience is normal or what to expect day by day. I’m going to try to post every day, so. I don’t miss anything.

If you haven’t had it and are looking into surgery, you might want to see if your insurance would pay for it as mine did.

I’d been thinking of having the surgery for years, even decades, and it actually took my husband losing his job to decide to try to get insurance to pay for it. I’ve had 2 neck fusions and still have major back issues, so my spine surgeon actually helped me set the wheels in motion to support my insurance claim.

But, I need to back up...I searched for a plastic surgeon for a while. I read reviews, asked people that I knew had any type of breast augmentation, include a couple of breast cancer survivors who had reconstruction. I even asked the women who run the store near me that specializes in bras for breast cancer patients. I probably over-researched, if there’s such a thing, but these are my breasts. They’ve fed children and given me and my husband pleasure for years...they’ve also been the bane of my existence since I got them in 8th grade. I finally settled on Dr. Kamal Sawan. I liked his website and I had a personal reference.

I called his office and one of the first things they asked me was whether or not I was going to try to have insurance pay for it. I said that I was, so they said to wait to get an appointment until I had a referral from my doctor. They said if I came in first, without a referral, my insurance company, United Healthcare (UHC), would consider it cosmetic and not pay anything for it. They sent me the specific guidelines that UHC uses so I could see exactly what UHC considers medically necessary. It’s called the ‘Coverage Determination Guideline’. The doctors office said there is very little difference between the insurance companies guidelines, but made sure to get my UHC specific one. United Healthcare guideline for breast reduction.

There were a number of things on the Indications for Coverage list that I didn’t know could be contributed to Macromastia, the term used for large breasts. Obviously I had back and neck pain, but headaches are also on the list, restriction of physical activities, bra indentations that don’t go away, rash under breasts, acquired kyphosis and ulnar paresthesias. I wasn’t sure what those last two were, so, of course, I googled them. Kyphosis is a rounding of the back that happens as a result of your large breasts. I had ulnar nerve release in 2015, which I had no idea could have been caused from my large breasts.

In addition to the above issues, you also have to have a certain amount of tissue that will be removed.   The calculation is on the guideline, but it’s some actuaries formula using height and weight with the amount of tissue removed. This part can’t be determined until you actually see the surgeon.

So, I had my doctors document and send to the plastic surgeon. We finally made an appointment and I apprehensively went to see Dr. Sawan. He took pictures of my breasts with his iPad and showed me where my breasts should be (sad how droopy they were), made some additional notes, asked me what size I really wanted to be and sent me on my way. There was nothing I could do now but wait to see if it got approved. So I went home to wait...