About six weeks after the letter was sent and several phone calls, I received (and the patient got the same copy) a letter denying the surgery as she failed to meet the minimal tissue removal guidelines. I need to remove how much tissue?!
I re-read the letter. They too referenced the Schnur sliding scale (SSS). I called the physician reviewer, feeling like they had just misunderstood. Their letter stated "tissue removed per breast". I understood the SSS to be "total tissue removed".
I actually had a very pleasant conversation / exchange with Dr Insurance. He listened and let my fax him my copy of the original article. He then called me back and informed me that I had misread the article. I was confused (granted it had been years since I had re-read it, but I "knew" what it said) but looked again as we talked. Damn, he was right. As he pointed out, the original article measured the amount of tissue removed from the RIGHT breast only and not both added together. So the scale is per breast not total tissue removed.
Well, I have been looking back over all the information I have and have finally figured out part of the source of my confusion (other than simply wanting it to be so, as it makes it easier to accommodate these women). I scanned in a copy of the BCBS Manuel page I printed out back in July 2001. Note the heading says "Total Breast Tissue to Be Removed". Today when I type in the web address at the bottom of the same page, this is what you will see "Tissue per Breast". Same web address, but they corrected it some time between 2001 and now.
Another example, 5'1" tall and weights 155 lb. This woman would have a BSA of 1.74 and would have to have 400 gms of breast tissue per side removed. That's at least 2 cup bra sizes for her.
That seems fair. It's hard to promise them (the patients) that you can remove that amount sometimes. It can also be difficult to estimate the amount to be removed just by exam. There was a recent article (see reference #2) that has a formula for the estimation. I may try it and see if it is any better than my "eye". The formula is 35 X sternal notch to nipple distance in cm + 60 X nipple to inframammary crease distance in cm - 1240.
The woman that prompted all this, I estimated about 200-300 gm less per side than required. I'm not willing to make her a "B" cup just to meet the requirements (see my reasons here). And over-estimating the amount and then not meeting it can get a "not covered" and no payment after the fact. Thankfully, Dr Insurance approved her for me. He felt that I was doing her for the "correct" reasons. I appreciate the discussion we had.
Reduction Mammaplasty: Cosmetic or reconstructive Procedure?; Annals of Plastic Surgery, Vol 27, No 3, Sept 1991, pp232-237
A Formula Determining Resection Weights for Reduction Mammaplasty; Plastic & Reconstructive Surgery. 121(2):397-400, February 2008; Descamps, Marjanne J. L. M.R.C.S.; Landau, Alex G. M.B.; Lazarus, Dirk F.C.S.; Hudson, Don A. F.R.C.S., F.C.S., M.Med.