Schnur Sliding Scale – Medical Neccessity

If you wish to proceed with surgery, you may do so at any time provided you are medically safe for anesthesia and choose to self-pay. However, if you want your insurance company to cover the procedure, you must comply with their specific requirements and approval rules. Please understand that Dr. Jacobsen does not control insurance company policies or their authorization decisions. Our staff is experienced in submitting insurance authorization requests, but it is important to be realistic: more than 90% of breast reduction requests are initially denied by insurance companies. Approval often requires persistence, documentation, and active participation from the patient.

Insurance-covered breast reduction is intended to remove weight to relieve physical symptoms such as pain and discomfort. It is not intended to improve appearance. Insurance companies do not cover procedures for cosmetic enhancement. While breast reduction can help relieve symptoms, a breast lift (mastopexy) is designed to improve breast shape and position and is not covered by insurance.

Insurance coverage for breast reduction is based almost entirely on the amount of breast tissue (by weight) that must be removed. Most insurers use the Schnur Sliding Scale, which determines the minimum required tissue removal based on your height and weight. From these measurements, your Body Surface Area (BSA) is calculated. In general, the higher the body weight, the greater the required amount of tissue removal.

You can calculate your BSA using the tool above.

Once your BSA is known, the Schnur Sliding Scale indicates the minimum number of grams of tissue that must be removed for insurance coverage. For reference, one pound of tissue is approximately 450 grams. For example, a woman who is 5’5” and weighs 160 pounds has a BSA of approximately 1.8 and would need about 450 grams removed to meet insurance criteria.

To put this into perspective, 450 grams is roughly the weight of a pound of ground beef. This is a substantial amount of tissue and, in many cases, exceeds the amount of breast tissue available in each breast. When the required amount cannot be safely removed, the procedure becomes a breast lift rather than a reduction, which is not covered by insurance.

Our goal is to help you understand these requirements clearly so you can make the most informed decision about your care.

Please reference pricing at this link if you wish to have a cosmetic breast lift (Mastopexy) Or Breast Reduction. www.drjsoffice.com/pricing

Body surface area and average breast tissue removed above 22nd percentile

For women, one of their top concerns when looking towards Breast Reduction is the pain that is associated with this condition.

Breast reduction is very important to women and for Dr. Jacobsen as well. For Dr. Jacobsen, this means taking care of those needing help alleviating back, neck, and shoulder pains that come from the grooving of their brassiere.

It can be challenging to get coverage from your insurance carrier. The criteria are strict and challenging to meet. Less than 10% of women obtain approval. Of those that are approved, many find that after the operation, the service is denied by their insurer, leaving you with a bill for surgery.

Dr. Jacobsen has been for years advocating for women to be approved by their insurers, but the process has been a disappointing failure for ladies and their families. The process is long and arduous and requires many of your resources and our office resources to battle for your approval.

As a result, Dr. Jacobsen will no longer assist in the approval process. If you can pre-approve and pre-authorize your breast reduction surgery, we will be happy to perform this for you under your insurance. But we no longer provide the exhaustive administrative service to authorize your operation for you.

Self-pay is always an option at our office. Our fees are reasonable and affordable for most.

www.drjsoffice.com/pricing

Almost all women wish to have their insurance company pay for this.

Most insurance companies make this very difficult and do not wish to pay for this type of service, making it very difficult to be approved and authorized for surgery.

Reading the material below will help yourself a great deal through this process.

But Dr. Jacobsen cannot assist you through this process. You can engage and complete this process long before you see Dr. Jacobsen or another surgeon.

Insurance companies deny greater than 90% breast reduction surgeries. You must work hard and fight for your approval!

But if you wish your surgery to do be done promptly and safely, please consider our reasonable fees, and your surgery will be scheduled for you right away, usually within a week.

Hope to meet you soon! Dr. Jacobsen & Staff

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Common Breast Reduction Misunderstandings

• Patients feel because they are suffering that your insurance company will cover the surgery.
• Patients feel that because their doctor said they needed breast reduction surgery that their insurance company will cover it.
• Patients feel if that if Dr. Jacobsen just words his notes properly the insurance company will cover it.

These are false

By allowing Dr. Jacobsen to take over your care, Dr.  Jacobsen will act as your best advocate. You can be assured that his notes will be very detailed and supportive. However, Dr. Jacobsen’s opinion alone is not final. The insurance company’s decision may rely ENTIRELY upon supportive documentation from other supporting providers. By meeting the criteria and having all the appropriate documentation on your behalf will allow for the greatest chance to be approved and covered by your insurance. These can be located by speaking with your insurance company.

Every insurance carrier is different and has a different process.

Steps to Finding Insurance Criteria

• Call your carrier and find the criteria they have for breast reduction surgery in your policy.
• Call your carrier and get a copy of your policy.
• Printout the criteria for breast reduction surgery.
• Document how you meet each criterion your insurance carrier has listed

If you contact your insurance, it is essential to tell and let your representative know that this breast reduction surgery is necessary to your health and well-being. They should be able to give you the exact criteria they use to approve breast reduction surgery.

By obtaining medical records, you can help yourself with the most important part of the approval process; Supporting documentation of problems relating to the size of your breasts and the wish to resolve this by having breast reduction surgery.

Dr. Jacobsen’s staff will not obtain these records for you.  If you wish to have your insurance company approve your surgery, you must obtain the records, email and/or fax them to us

Once you meet the criteria you cannot be denied for surgery! If you want your surgery work on this diligently.

List of Medical Records Needed for Approval:

You can send these to Dr. Jacobsen’s office

• Primary care physician
• Referring physician
• Back or spine physician
• Physical therapist
• Records from any other non-surgical physicians

You can be your own best advocate by physically getting your own records. You must go to your doctor’s office and request these records and bring them to our office.

Records can be faxed to 602279.1701 or emailed to emaildrj.com.

The best method is sending your records on your own behalf, oftentimes by calling other offices and asking them to fax your information usually fails. As offices can be extremely busy and sending records becomes of low priority when dealing with higher risk patients. We receive all faxes electronically, so we do not miss any faxes. We recommend going to your doctor’s office to obtain copies and bringing them at time of appointment. We will not call your doctor’s office to retrieve documentation. Once we receive your documentation, we will be happy to submit them to the insurance companies on your behalf. We cannot be your administrative assistant. If you wish your surgery to be approved you must obtain your records on your own.

Call your carrier during the approval process:

• They can help give you the status of your approval or denial.
• Insist that they tell you why you are not approved.
• Insist that they tell you specifically what criteria you have not met.
• Do not believe them when they say you are denied because Dr. Jacobsen did not do the authorization properly.

Be Aware of Carrier’s excuses

Insurance companies will often tell patients that they are not approved by fault of the practitioner, and they are the cause of your denial. To avoid this, make your carrier explain to you what criteria you do not meet exactly!

Be assured once we receive records we have done everything properly and timely. Our office handles the insurance authorization process daily, quickly with no problems and knows exactly how to do it. Before taking any complaints to the office make sure of the denials you are receiving from the insurance carrier. Authorizations are based solely on the criteria you receive from your insurance company.

If your surgery is still denied by your insurance company, we will be happy to work with you. Attached is an Estimated Cost for Surgery for your information.  After a consultation, we will prepare a more accurate personalized Financial Commitment for Surgery for you.

At any time during this process, you can contact our office for an update on status or to answer any questions you may have at emaildrj.com.

And remember . . .  You must work hard and fight for your approval!

Fax: 602.279.1701

Email: info@drjsoffice.com

If you are considering surgery, below is the Consent form for you to read prior to your Surgery

Informed Consent 

Breast Reduction  

William M. Jacobsen, M.D., FACS 

Cosmetic & Restorative Surgery 

2525 East Arizona Biltmore Circle  Suite C236  Phoenix, AZ  85016 

Phone 602.212.0100  Fax 602.279.1701 

www.drjsoffice.com                 

Secure Text: 623.888.8152 

©2020 American Society of Plastic Surgeons®. Purchasers of the Informed Consent Resource are given a limited license to modify documents contained herein and reproduce the modified version for use in the Purchaser’s own practice only. The American Society of Plastic Surgeons® does not authorize the use of these documents for purposes of any research or study. All other rights are reserved by the American Society of Plastic Surgeonsâ. Purchasers may not sell or allow any other party to use any version of the Informed Consent Resource, any of the documents contained herein, or any modified version of such documents. 

INSTRUCTIONS 

This document is about informed consent. It will tell you about reduction mammaplasty surgery (breast reduction), its risks, and other treatment options. 

It is important that you read this whole document carefully. Please initial each page. Doing so means you have read the page. Signing the consent agreement means that you agree to the surgery that you have talked about with your plastic surgeon.  

GENERAL INFORMATION 

Women who have large breasts are likely to have health problems. The weight and size of their breasts can make their back, neck, and shoulders hurt. Their skin can get irritated. Breast reduction is usually done to remove these symptoms rather than make the breasts look better. This surgery can also reduce the areola, that is, the dark skin around the nipple. Breast reduction works best for healthy, emotionally stable women who are realistic about what the surgery can do. Surgeons have many ways to reduce and reshape women’s breasts. Breast reduction leaves permanent scars that you can see on your breasts. There are risks and complications of reduction mammaplasty surgery. 

OTHER TREATMENTS 

Surgery is not the only option. Other treatment options include not going in for surgery, opting for physical therapy to relieve the pain, and wearing undergarments made to support large breasts. Some patients may also get liposuction done to reduce the size of their breasts. All treatments have their risks and possible problems. 

RISKS OF REDUCTION MAMMAPLASTY SURGERY  

Every surgery has risks. It is important that you understand the risks and what can result from them. Every procedure has its limits. Choosing to have surgery means comparing the risks and benefits. Most patients do not have these problems, but you should talk about them with your plastic surgeon. Make sure you understand all possible outcomes of the reduction mammaplasty surgery. 

SPECIFIC RISKS OF REDUCTION MAMMAPLASTY SURGERY 

Asymmetry: 

Most women’s left and right breasts do not look the same. Differences in breast and nipple shape, size, or symmetry may occur after surgery. You may need another surgery to fix the asymmetry. Surgery may not totally fix the asymmetry. There is a possibility that insurance may not cover symmetry.  

Change in Nipple and Skin Sensation:  

You may feel less or no sensitivity in the nipple and breast after surgery. In some cases, you may be much more sensitive. Partial or permanent loss of nipple and skin feeling can occur after a mastopexy in one or both nipples. A nipple graft removes the nipple and replaces it as a skin graft. You will lose sensation in the grafted nipple. Changes in sensation may affect your sex life or your ability to breastfeed a baby.  

Breastfeeding:  

A woman may have a breast reduction with a nipple graft. That means the nipple is removed and replaced with a skin graft. That means she can probably no longer breastfeed. Pedicle surgery and liposuction may spare the breast ducts. In such a case, it may be possible to breastfeed after the breast reduction. You may not be able to make enough milk to nurse a baby even with these techniques. 

Unsatisfactory Results: 

You can expect good results. However, there is no guarantee or warranty for the outcomes. You may be unhappy with the results of the reduction mammaplasty surgery. Your nipples may be uneven. Your breast may be an unexpected shape and size. The nipples or breasts may not work like they are supposed to. Your wound may open and not heal well. You may lose sensation after the surgery. Healing may result in losing a nipple, which would require more surgery to reconstruct it. There is no way to predict the final breast size (bra cup size) after surgery. Your breasts may be smaller, but the bra cup size may not change. You may have unwanted scars or visible deformities at the ends of the cuts (dog ears). You may need liposuction to thin the breast tissue that is outside of where the surgeon usually does the reduction mammaplasty. You may need another surgery to try to improve your results. You will not be able to breastfeed if your surgeon uses certain methods. Having more surgeries may NOT fix unwanted results. 

Breast Disease:  

You can get breast disease and breast cancer without having reduction mammaplasty surgery. People who have had breast cancer or whose family members have had breast cancer may be at a higher risk of developing breast cancer. All women should regularly do a self-examination of their breasts. You should also get routine mammograms, according to American Cancer Society guidelines. You should see a doctor if you think you have found a lump. If a lump is found before or during breast surgery, you may need more tests and treatment, which will come with their own costs. 

Wound Healing Issues: 

Even when the surgery goes well, the areas where the surgeon made the cuts may not heal correctly. This may lead to scarring, asymmetry, and unwanted results. You may need more surgery. The skin, nipple, or the fat inside the breast may die (called skin, nipple, or fat necrosis). This may lead to a result you do not want, and you may require more surgery. If fat inside the breast dies, it can leave a hard lump in the breast. You and your surgeon may opt to remove the hard lump. Having another surgery may not restore your breast to “normal.” 

Nipple and Areolar Necrosis: 

It is very rare, but the areola (around the nipple) and the nipple can have poor blood flow after surgery. This can result in the death of the tissue. That will leave a wound and make healing slow. The nipple and areola can be reconstructed if needed. 

Long Term Results: 

Doctors cannot predict how pregnancy, weight change, and aging will affect the results of a breast reduction. If you are planning on losing a lot of weight or getting pregnant soon, you can put off the breast reduction surgery to avoid possible unwanted effects and results. 

DISCLAIMER 

Informed consent documents give you information about a surgery you are considering. These documents explain the risks of that surgery. They also discuss other treatment options, including not having surgery.  

However, informed consent documents can’t cover everything. Your plastic surgeon may give you more or different information. This may be based on the facts of your case. 

Informed consent documents are not meant to define or serve as the standard of medical care. Standards of medical care are determined based on the facts involved in an individual case. They may change with advances in science and technology. They can also change with the way doctors practice medicine.  

It is important that you read the above information carefully and get all your questions answered before signing the consent agreement on the next page. 

CONSENT FOR PROCEDURE OR TREATMENT 

1. IpermitDr. ​William Jacobsen​ and the doctor’s assistants to do the procedure Breast Reduction.  
2. Igotthe information sheet on Breast Reduction. 
3. 3. Iunderstandthat, during the surgery, an unexpected situation may require a different medical procedure than the surgery listed above. I permit the doctor listed above, the assistants and/or designees to do any treatment that my doctor thinks it is needed or helpful. My permission includes all treatments that my doctor does not plan to do at the start of the  
4. 4. I understand what my surgeon can and cannot do. I understandthat no warrantiesor guarantees have been hinted at or stated outright about the outcome of the surgery. I have explained my goals. I understand which outcomes are realistic and which are not realistic. All my questions have been answered. I understand the surgery’s built-in risks. I am aware of other risks and possible issues, benefits, and options. I understand and choose to have the surgery. 
5. Iagreeto the anesthetics that are needed or helpful. I understand that all types of anesthesia have risks and may result in complications, injury, and sometimes death. 
6. 6. I am awareof the seriousrisks to my health when blood products are used. I agree to my doctor using them if my doctor, assistants, and/or designees think they are needed or helpful. 
7. 7. Iagreeto the disposal of any tissue, medical devices, or body parts taken out during or after the planned surgery or any other operation that is needed or helpful. 
8. 8. Iagreeto have the right parts of my body photographed or televised before, during, and after the surgery for medical, scientific, or educational reasons, if the pictures do not reveal my identity. 
9. 9. For medical education, Iagree that onlookerscan be in the operating room. 
10. Ipermitmy Social Security Number to be given to the right agencies for legal reasons and medical device registration, when necessary. 
11. 11. I agree to thecharges for this surgery.I understand that the doctor’s charges are separate from the charges for the hospital and the a I understand that there may be more charges if more procedures or treatments are needed or helpful. I agree to the charges, if any. 
12. 12.   Iunderstand thatnot having the surgery is an option and that I can opt-out of having the surgery.  
13. 13. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
14. THEABOVESURGERY TO BE PERFORMED 
15. THEREMAY BEOTHER SURGERIES OR TREATMENT OPTIONS 
16. THERE ARE RISKS TO THE SURGERY