Getting breast reduction covered by insurance [Dan Zegzula, MD, Portland]

Dr. Zegzula (00:00):
Dan Zegzula. I'm a plastic surgeon, Portland, Oregon at the Portland Plastic Surgery Group.

Eva Sheie (00:07):
There used to be rules around breast reduction that you could only do it a certain way if you wanted it covered by insurance. Is that still true?

Dr. Zegzula (00:13):
Insurance companies aren't telling us how to operate very much, but what they'll tell us is that you have to remove a certain amount of breast tissue to make sure that it is what they call a functional case. I think insurance companies think that we would like to do cosmetic surgery and get paid by the insurance company, which really isn't true. But they feel, they approach every breast reduction like it's a cosmetic case, like it's just a patient wanting smaller, higher breasts when in fact, so many women suffer with chronic pains because of the weight of their breast tissue, back, neck, shoulder pains, headaches, even numbness and tingling down into the hands. But despite all those complaints and the fact that they don't get better with conservative treatment, you still have to remove enough tissue to make the insurance companies satisfied that it was a functional operation, not a cosmetic operation. And there's a formula for that.

Eva Sheie (01:09):
How do they know that you actually did it?

Dr. Zegzula (01:12):
Good question. Early in my practice, you had to submit a pathology report for every breast reduction that you did. And of course, the pathologists, when they got the breast tissue specimen would weigh it and then they would go by that weight. Thankfully, that hasn't happened in a while. They're trusting us that we're doing the operation that we said that we would and removing enough breast tissue.

Eva Sheie (01:38):
Portland Plastic Surgery is one of the few places, at least in the Portland, Vancouver area and maybe the entire Pacific Northwest, where insurance is still accepted for breast reduction. And curious why you've made that such a priority for the practice?

Dr. Zegzula (01:55):
Because there's a great need out there. Honestly, breast reduction patients are some of the happiest, most satisfied patients we have. It feels good to see your patient post-op and big smiles and, oh my gosh, this changed my life. Best thing I've ever done for myself, and I'm not in pain anymore and my clothes fit and I can exercise. Yeah, so many good things with breast reduction. So if we were to limit ourselves to just doing it outside of insurance, we'd probably only do about half the number of breast reductions that we're doing. I think it's about 50/50 in our practice, whether they're paid for with insurance or without.

Eva Sheie (02:34):
On this podcast, we bring you directly to the doctors who are where before meets after Links to our guest's website and contact info are in your show notes. Follow us on Instagram @wherebeforemeetsafter. Where Before Meets After is a production of The Axis, the podcast agency for Aesthetics, theaxis.io.