Ask a doctor

I'm 5' and 250lb with back Pain, Am I Candidate for Insurance to Cover A Breast Reduction.

I'm 5ft tall, 250lbs and 44dd. My breasts hang low yet never had children. Am I a good candidate for a reduction covered by insurence? My back hurts constantly. 

Doctor Answers (7)

Insurance

+1
You should lose weight before your surgery.  Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.
Best wishes,

Dr. Basu
Houston, TX


Houston Plastic Surgeon
4.5 out of 5 stars 117 reviews

Insurance coverage for a breast reduction

+1

Every insurance company has their protocol for determining coverage for a breast reduction.  You can call a claims representative to review your particular contract.  You appear to be a good candidate.  As a plastic surgeon all we can do is give an honest estimate of how much breast tissue will be removed.  This is only an estimate.  As a plastic surgeon I work for the patient and not the insurance company and I will perform the operation using my best judgement and will not be dictated to by an insurance company who will never assume any of the liability of the operation goes bad because they "require" 500 grams to be removed.  It is a no win situation at times.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance reqirements for Breast Reduction surgery

+1

Hi,

Document, document, document! The more physicians you can get to recommend a breast reduction to relieve your symptoms, the more likely you are to get approved. Insurance companies make money by denying coverage, so it is your job as a policy holder to 'build your case'. Begin with your primary care physician, pain specialist, chiropractor, back/spine specialist, ob/gyn, etc.

I strongly suggest that you lose weight prior to your breast reduction. In general, insurance companies require at least 500g (1lb) of breast tissue be removed from each breast. If you are only a DD, then removing that much tissue may make you too small for your frame. If this is an issue, please consider financing the surgery yourself. I strongly believe that a patient should get the results she desires and not what an insurance company dictates. Best wishes, Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 125 reviews

You might also like...

Insurance coverage for breast reduction.

+1

Insurance Coverage for Breast Reduction

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.
 

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

I'm 5' and 250lb with back Pain, Am I Candidate for Insurance to Cover A Breast Reduction.

+1

From your description you would not be approved based upon the Metropolitian Life Insurance ht vs wt tables. That does not mean you are not a good candidate for a breast reduction. it just means you are not meeting the citeria for that insurance company's guidelines. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 62 reviews

Breast reduction insurance coverage

+1

Based on your description you may be a good candidate for breast reduction surgery; it may be in your best interest to drop weight first.

The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.

This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're saying a well-trained/experienced board-certified plastic surgeon. Good luck!

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 723 reviews

Insurance covered breast reduction

+1

Each medical insurance company  has its own guidelines regarding eligibility for breast reductions.  If the weight of your breasts is causing chronic symptoms such as neck, shoulder and back pains and the symptoms can be documented, your insurer may cover the procedure.  Good luck! 

Joseph N. Togba, MD
Oakland Plastic Surgeon
4.5 out of 5 stars 11 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.