Breast Reduction Information Requested by Insurance for Pre-Determination
Medical record history documenting significant symptoms that interfere with activities of daily living, including but not limited to:
1. Long standing duration of pain in the upper back, neck and shoulders with increasing intensity and is not related to other musculoskeletal causes (e.g., poor posture, acute strains, post-traumatic conditions, poor lifting techniques, or other evidence of over use) and/or
2. Persistent clinical, non-seasonal submammary intertrigo, which is refractory and unresponsive to comprehensive local hygiene and topical anti-infective therapy and/or
3. Ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and/or hands.
The patient's physical exam (in the plastic surgeon's office) documenting the following:
1. Significant shoulder grooving or ulceration of the skin of the shoulder and
2. Obvious breast hypertrophy (photographs are necessary) and
3. Suprasternal to nipple measurements of greater than 28 cm for women greater than or equal to 5'2" tall or 25 cm for women less than 5'2" tall and
4. Physical exam consistent with symptoms precipitating request for Reduction Mammoplasty.
Failure of comprehensive conservative measures/treatment including:
1. A minimum of six weeks of physical therapy for back, neck or shoulder pain, including a maintenance home exercise program and
2. An appropriate support bra with weight distributing straps and
3. Anti-inflammatory agents unless medically contraindicated and
4. Symptomatic measures, including application of heat and cold and
5. Appropriate local hygiene and topical pharmacologic treatments for intertrigo and
6. A documented medically supervised attempt to reduce and maintain weight if Body Mass Index (BMI) is greater than 27. Status of weight loss.
7. Incapacitation of a normal life due to breast weight and size.
Please note: All information submitted regarding the patient's therapy treatments, medications for pain and chiropractor sessions, should include specific documentation on the timeline of symptoms and the dates of failed treatments
**Without this information, insurance will surely deny surgery.**