United Healthcare
Breast reduction surgery can alleviate many symptoms caused by hypertrophic (abnormally enlarged) breasts and is a medically necessary procedure to improve a patient’s quality of life. If you have United Healthcare health insurance, you may be eligible to have a breast reduction surgeon of your choice covered by your health care plan by using your out-of-network benefits.
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Most insurance carriers offer HMO (Health Maintenance Organization) plans and PPO (Preferred Provider Organization) plans. HMO plans do not offer out of network benefits whereas PPO plans can offer patients access to physicians that are not in their health care plan network via out of network coverage. Insurance cards will oftentimes specify if out of network coverage is offered. If you are unsure if network coverage is a part of your plan or would like to learn more about your coverage options please call the number on your insurance card.
In order to have your breast reduction surgery covered by United Healthcare, you must meet certain criteria as outlined by their breast reduction coverage guidelines.
According to United Health Care’s breast reduction coverage determination policy a breast reduction is deemed medically necessary when a patient’s macromastia (abnormally enlarged) breasts causes them to suffer functional impairment that cannot be alleviated through non-surgical interventions.
According to United Health Care’s breast reduction coverage determination policy, a patient must have some of the following functional impairments that are attributable to macromastia:
United Healthcare uses the Modified Schnur Nomogram Chart to determine the required amount of tissue that needs to be removed to qualify. This nomogram uses a patient’s body surface area (body weight and height) to determine the weight of breast tissue to be excised. This amount must be greater than the 22nd percentile of the Modified Schnur Nomogram Chart and additionally, the proposed procedure is likely to result in significant improvement of the functional impairment.
During your consultation at HIM & HER Plastic Surgery, your plastic surgeon will perform a detailed history and physical and document any signs and symptoms you may be experiencing from your hypertrophic breasts. Your plastic surgeon will also document any remedies that you may have tried in the past to improve your symptoms. After performing a comprehensive physical exam and taking pictures your surgeon will determine how much breast tissue that would be excised in order to alleviate your symptoms.
After your consultation at HIM & HER Plastic Surgery, your plastic surgeon will write a letter of medical necessity to United Healthcare on your behalf. If your surgery is deemed medically necessary, United Healthcare will grant a pre-authorization letter that approves your surgeon to perform the surgery at a designated facility.
Using out of network benefits to cover your breast reduction may seem like a daunting task. Our team at HIM & HER Plastic Surgery is here to guide you in your journey to getting your breast reduction covered by your insurance plan. Having a board certified plastic surgeon who understands your goals makes the journey worthwhile. A breast reduction is a life changing surgery that improves both quality of life and body image.
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