How Does Someone Qualify For An Insurance Approved Breast Reduction?

I am currently a 32G up from a 32F pre-pregnancy. I find myself with extreme upper back pain at night when I sleep. My bras are very uncomfortable. I am 5'4 130 pounds pre-pregnancy (currently 151 at 24 weeks pregnant). I am wanting to see if you think I might qualify for insurance approve breast reduction. I find my self having to get massages every month to 2 weeks just to maintain.

Doctor Answers (9)

Qualifying for coverage for breast reduction

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Whether breast reduction is covered by insurance is depedent on each patient's physical symptoms, characteristics as well as types of insurance that she carries.  Unfortunately, it is getting harder to get breast reduction covered  by insurance.  Please review your insurance policy in regards to breast reduction.  You want to have documentation of your symptoms (back pain, shoulder pain, shoulder grooving, rashes).  Insurance companies may also want your height and weight and photos of your chest as well as your efforts to lose weight to decrease your breast size.  Your physcians/plastic surgeon can be your advocates and talk with your insurance company as well. 


Houston Plastic Surgeon
4.5 out of 5 stars 36 reviews

If the insurance company considers breast reduction medically necessary

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I have reviewed  requests for over 20 years from numerous insurance companies as to whether breast reduction will be covered. Insurance companies will cover a medically necessary procedure. They have certain criteria that need to be met, to make it medically necessary. Some of these criteria include a documented history of neck and shoulder pain, a one year documented history of recurrent infections developing underneath the breast from moisture accumulation that have been treated by a physician, that the patient is within 20% of their ideal weight, and that a certain amount of breast tissue is to be removed from each side (usually a minimum of 500 g).

Read your insurance policy carefully to see if you meet their criteria and then discussed the case with your physician.

Joseph M. Perlman, MD
Houston Plastic Surgeon
5.0 out of 5 stars 8 reviews

Breast reduction insurance coverage

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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 708 reviews

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Insurance criteria for Breast Reduction surgery

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Hi,

Certain criteria has to be met before insurance approval. Call your carrier and find out what these are. FYI, the more documentation you have that your large breasts are causing you trouble, ie. back, neck, shoulder pain, headaches, decreased quality of life, difficulty sleeping- exercising, rashes, etc., the more likely you are to be approved. These symptoms should be documented by your OB-Gyn, primary physician, pain specialist, chiro, spine specialist, orthopedist, etc. Photos will be taken by your surgeon and sent in to your insurance along with any supporting documentation of your symptoms. Over the years, I've seen women who really needed a breast reduction denied repeatedly and some who were borderline large get approved. It almost seems like 'luck of the draw' when it comes to dealing with insurance companies. Now, in general, most insurance carriers will require at least 500g to be removed in each side. For some women this amount will make them too small for their frame, causing a poor aesthetic outcome. So, if this is the case for you, please consider financing the surgery yourself. It's best to pay for what you want, than to be unhappy with what your insurance wants. Best of luck to you,

Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 123 reviews

Insurance coverage for breast reduction.

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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

Questions about insurance coverage for a breast reduction

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You may very well be able to have your insurance cover your breast reduction. However, criteria and even coverage in general depends on your particular insurance company and the specific plan. Some plans have an outright exclusion for breast reduction period.

Insurance plans have various criteria that you would have to meet in order to be able to get authorization for the surgery. What is required varies among the different insurance companies and can include a specific amount of breast tissue (in grams) that would need to be removed that is also influenced by your height and weight. They also require documentation of a constellation of symptoms such as neck, back and shoulder pains, skin rashes, shoulder grooving, postural changes, etc. Many want evidence of failure of non-operative treatments such as physical therapy.

Seek a consultation with a board certified plastic surgeon in your area who could help you with all the issues related to pursuing and undergoing a breast reduction.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 20 reviews

Breast reduction insurance approval

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The most important part of getting qualified for breast reduction surgery is having a history of evaluation and treatment for your symptoms of enlarged breasts.  Almost all insurance companies will require documentation to prove you have the expected symptoms of large breasts.  Insurance companies want to make sure they are not paying for a cosmetic procedure; they want to improve your symptoms and ability to function.

After you have established a record of treatment for your enlarged breasts you should have a consultation with a plastic surgeon that can then preauthorize you for the procedure.  Each insurance company will have different criteria so it is helpful for you to discuss this with your company as well.

Best Wishes

Dr. Peterson

Marcus L. Peterson, MD
Saint George Plastic Surgeon
4.5 out of 5 stars 13 reviews

Insurance coverage for breast reduction

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Insurance coverage for breast reduction varies by insurance carrier and plan.  In addition to large breasts and symptoms such as back, shoulder and neck pain, grooving in the shoulders caused by bra straps and recurrent rashes between or beneath the breasts.  While your breast size and complaints  would probably meet these criteria, insurance carriers may also require a period of conservative treatment.  This may include physical therapy, medications, etc.  After you have had your child, I would recommend that you contact your insurance company directly to find out if they cover breast reductions as well as their specific guidelines.  You should also schedule consultations with board-certified plastic surgeons to learn more about the procedure and how you may benefit from having it performed.

Good luck.

 

Craig S. Rock, MD
Houston Plastic Surgeon
5.0 out of 5 stars 16 reviews

Breast reduction in patients who have symptoms due to the large size of their breasts will

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often qualify for insurance coverage.  While each plan has its own variations, and approval needs to be determined before surgery, you sound like someone who would meet the criteria for coverage of most plans.  Specifically, symptoms such as back, neck or shoulder pain, deep grooves under the bra straps, and recurrent infections where the skin of the breast meets the skin of the chest wall under the breast are factors that can establish the need for surgery.  If you have seen a physician or chiropractor for any of these complaints be sure to obtain documentation of the visits for your plastic surgeon to submit to youe insurance company.  This history can help establish the history of symptoms and the benefit of surgery to reduce the symptoms.  Breast reduction patients are often among the most satisfied in our plastic surgical practice because they not only look better after the surgery, they feel better after the surgery.  Good luck...

Michael H. Rosenberg, MD
White Plains Plastic Surgeon
5.0 out of 5 stars 1 review

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.