Skip to content

Insurance Requirements for Covered Surgeries

Breast Reduction

The following documentation requirements are requested by all insurance companies to be considered as proof for medical necessity for a breast reduction.  The amount of breast tissue that is estimated to be removed also plays a major role in an approve by insurance, but this varies based on the specific insurance company and your body surface area.

  • Six weeks of chiropractic or physical therapy treatment in the past 12 months.  We would need copies of these treatment records (not just a letter, but all records) to submit with the prior authorization request for this.
  • Documentation of a support bra fitting.  This can be obtained from anywhere other than Victoria Secret that does bra fittings (Lane Bryant, The Bra Shoppe, Dillards, Soma-- to name a few).  You would need to get a business card with the company, name of the person who did the fitting, and your bra size.  We would need this to submit to insurance also.
  • If your Body Mass Index (BMI) is over 27, your insurance company will want to see that you have attempted  weight loss to reduce the size of your breasts.  This could be nutrition records or simply weigh ins with your Primary Care showing your weight reducing on the weigh ins.  Weigh ins showing weight gain is not supportive documentation for this requirement.
  • If your insurance is AETNA, they also require any females over the age of 40 years of age or older to submit a copy of their most recent mammogram report that was negative for cancer and performed within the two years prior to the date of the planned reduction.

In order to submit a prior authorization request to your insurance company, we would need all of the above mentioned documentation in the office before the submission of request.

 Panniculectomy (removal of abdominal pannus following weight loss)

The following documentation requirements are requested by all insurance companies to be considered as proof for medical necessity for a panniculectomy.

  • If weight loss is due to gastric bypass surgery, you must be 18 months post-op from your surgery AND have maintained your weight for the past 6 months. (We will need a copy of the bariatric surgery operative note to send to your insurance company with the prior authorization request to document timeline)
  • Must have effects on your daily life activities due to the pannus which you can describe.
  • Have at least three months of clinical documentation where you have been treated for skin rashes due to the excess skin without cure of the rashes.
  • The abdominal pannus must hang at least 3-4 inches past your pubic symphysis which we will document with photographs at your consultation.

In order to submit a prior authorization request to your insurance company, we would need all of the above mentioned documentation in the office before the submission of request.

Blepharoplasty (Functional Upper Lid)

The following documentation requirements are requested by all insurance companies to be considered as proof for medical necessity for a panniculectomy.

  • Copies of your taped and untaped visual fields from your ophthalmologist showing improvement in vision with taping the eyelids
  • We will take photos in the office at your consult to also submit to your insurance company with the visual field documentation.

In order to submit a prior authorization request to your insurance company, we would need all of the above mentioned documentation in the office before to submission of request.