When Is Breast Augmentation Surgery or Breast Reduction Surgery Medically Necessary?
Independent Review Organizations (IROs) Help Payers and Providers Make Informed Decisions on Care
(PRWEB) February 23, 2005 -- Traditionally, breast augmentation (augmentation
mammaplasty) and breast reduction (reduction mammaplasty) surgeries are defined
by health insurers as cosmetic. It’s a definition that often puts patients at
odds with health insurers. Payers have difficulty deciding if breast enhancement
or breast reduction cases are medically necessary.
For example, a doctor
prescribes a breast reduction for Andrea, a five-foot one-inch, 135 pound,
32-year-old female. Her plastic surgeon recommends removing 500 grams of breast
tissue from each breast. Is this breast reduction surgery considered medically
necessary and something that is covered under her medical insurance plan?
According to Dr. Skip Freedman, medical director at AllMed Healthcare
Management, a leading Independent Review Organization (IRO), Andrea should
qualify for the breast reduction treatment because of the following
reasons:
• For several years, she has complained of shoulder, back and
neck pain, bra strap grooving and intertrigo (eczema).
• She wears a 34DD
bra and attributes these symptoms to her breasts.
• She’s worn support bras,
taken non-steroidal anti-inflammatory drugs (NSAIDs) and has had years of
chiropractic treatments without alleviating her symptoms.
• She has symptoms
consistent with macromastia (excessively large breasts)
• Her doctor notes
that her complaints are typical for a macromastia diagnosis.
According
to the American Medical Association (AMA), when reconstructive surgery, such as
breast augmentation or reduction, is performed on an abnormal structure of the
body caused by disease, infection, congenital deformity, trauma or tumors, the
reconstructive surgery is considered medically necessary and generally done to
improve the body’s function.
Breast surgery, rather than conservative
treatment or weight loss, provides the best chance for Andrea’s relief.
Additionally, patients, like Andrea, who have congenital breast deformity or who
have experienced breast trauma, infection, tumors or disease, may also qualify
for breast augmentation or reduction when it’s considered reconstructive. These
patients might have Poland’s Disease or cancer, breast drooping caused by
dramatic weight loss due to gastric surgery, significant breast asymmetry, or
have had a mastectomy.
When unsure, the AMA is encouraging third-party
payers to refer to such definitions in determining what services are eligible
for coverage under the plans they offer or administer, as well as leverage the
expertise of Independent Review Organizations for any questionable cases.
Independent Review Organizations offer a deep panel of experts that understand
the definitions of cosmetic and reconstructive breast surgery and can help
payers ensure patient treatments are medically necessary. Independent Review
Organizations can also help doctors confirm their diagnosis by reviewing clear
documentation and the high-resolution photographs of the breast area and any
other areas affected.
For more information on making informed decisions
on whether breast enlargement or breast reduction is medically necessary, visit
AllMed’s web site at www.allmedmd.com.
About AllMed Healthcare
Management:
Allmed Healthcare Management reviews claims for issues of medical
necessity, standard of care, experimental / investigational, hospital quality
management, code unbundling, fraud, and other issues that affect healthcare
decision-making.
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Source : http://www.prweb.com/releases/2005/2/prweb210591.htm