Dr Vent!

SQBEAR37 · December 12, 2003

I don't understand! I went to my Dr about a breast reduction(he is fresh out of med school and the newest Dr in the group) and he says the insur may not approve me cause of my weight. I am 4ft 9in and i weigh 195(i just lost 25lbs with weight watchers) i am a 42 DD. He did say that the insur will approve lap band(i have Health Net) i told him that i don't meet the criteria for wls...but i did tell him to go ahead and submit the paperwork for breast reduction. Why would the insur approve the more expensive surgery(wls)...I just don't understand! Has anyone else experienced this?

GeezerSue · December 12, 2003

1) Your BMI is over 40 and that is more important than your weight. (He's probably used to taller people and, therefore, higher weights. Many companies say "100 pounds overweight," but most say "a BMI of at least 40.")

2) The costs of the two surgeries should--in a perfect world--have no bearing on which is approved and which is not.

Don't put yourself in a position of thinking "Well, if I have to choose, the surgery i want is..." If both surgeries are medically indicated, and you want both surgeries, your insurance should pay for both, unless your policy excludes one or the other. Just be prepared to appeal any denials AND--if the situation presents itself--learn how to write an effective appeal.

Good luck,

Sue

BEBBLY · December 12, 2003

Your BMI is 42.2. You will definitly lose some of the breast with weight loss.

quakergirl · December 12, 2003

Perhaps they think the WLS will save them money in the long run by also reducing your risk of other health problems.

Like the others said, you would probably qualify for WLS. My understanding is that the standard is usually 100 pounds OR a BMI >40.

There is no way to predict just how much of your weight will come off your chest just from weight loss though. It depends on whether your breasts are mostly made of fat or if they're mostly glandular tissue (the latter doesn't shrink much with weight loss).

I was pretty flat-chested for as fat as I was, but yet my boobs are staying pretty much the same size as I lose weight - because apparently my body wasn't storing much fat in there to begin with.

I can understand your annoyance. Don't get the WLS if you don't want it. It's important to be motivated and emotionally prepared to make the lifestyle change, so being pressured into it by insurance is not the way to start.

Even if it means doing the surgery as a self-pay, you're better off getting the surgery that you want, not just what works for the insurance.

Good luck!

GeezerSue · December 12, 2003

Oh, yeah...the BR weight loss. It won't be much. My kid went from a 36 or 38J (yes, Virginia, there IS a D-cup), down to a tidy little 36D and they removed less than four pounds of tissue.

BUT...I'd think you'd want the WLS prior to the BR. Otherwise, as you lose weight, the sisters will be heading south all over again.

Sue