I Am 5'4" 110 and Have a 32dd Chest. Why Won't my Insurance Cover It?

My shoulders, neck and back are always hurting. I'm a petite woman and I can't afford thousands of dollars for a surgery. I don't understand why health insurance won't cover it. I understand why they wouldn't cover a breast enlargement, however, to reduce the size, it would benefit my health and well being. What am I supposed to do? I feel like I have no options.

Doctor Answers (12)

Insurance Coverage for Breast Reduction

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Insurance Coverage for Breast Reduction

Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
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.
 


Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast Reduction and Insurance Coverage?

+1

Thank you for the question.

There is no way of an online consultant knowing why your breast reduction coverage was denied. Corresponding with the  insurance company however may be helpful. It may be necessary to appeal the denial. Otherwise, it may be necessary to change your insurance plan.

Sometimes persistence pays off;  continue to be a “squeaky wheel”.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 751 reviews

Breast reduction

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Every insurance company is different a d some plans specifically exclude breast reduction as a covered benefit. Other plans require a long period of physical therapy prior to approval.

David L. Abramson, MD
New York Plastic Surgeon
3.0 out of 5 stars 4 reviews

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VIDEO ( breast reduction)

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Schedule an appoointment with a plastic surgeon and have them compose a predetermination of benefits letter to your insurance carrier.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 44 reviews

Insurance coverage of breast reduction

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The short and nasty sounding answer is that you gave control of your health care needs to a third party and they now get to decide what you can and can't have. You can imagine how this might work with the federal government bureaucracy managing your other health care needs and decisions. If you asked an insurance company or the government to pay for your groceries you would run into the same thing in terms of what you want and feel you need and what they would let you have or pay for. 

I recommend finding a board certified plastic surgeon who can do breast reductions in an accredited office surgical setting under IV sedation and local anesthesia. This minimizes the costs involved and avoids the problem of getting permission from a third party to do the procedure. It would be handled as if it were a cosmetic procedure even though it's not. There are financing companies available for spreading out the cost or wait until you can pay for it (and know exactly what the cost will be). 

Another alternative is to see if the university medical center with plastic surgery residents near you would do the procedure for a reduced amount as part of training for plastic surgery residents with plastic surgeons as supervisors. In dentistry or oral surgery this is a common way that people get dental procedures done that they feel they need and can't afford or get insurance to pay for.

Scott L. Replogle, MD
Denver Plastic Surgeon
4.0 out of 5 stars 1 review

Insurance and breast surgery

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Each insurance company is a bit different when it comes to coverage for a reduction. You have to contact your insurance company with regards to their requirements.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Insurance coverage for Breast Reduction

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If you have documented symptoms such as back pain, neck pain, and shoulder pain from large breasts, sometimes insurance companies cover breast reduction surgery. It depends on your health insurance policy as well as findings from your doctors. I would ask your insurance company if it is a covered benefit and see a plastic surgeon on your plan. 

Hayley Brown, MD
Las Vegas Plastic Surgeon
5.0 out of 5 stars 21 reviews

Breast reduction insurance coverage

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in answer to your question:

My shoulders, neck and back are always hurting. I'm a petite woman and I can't afford thousands of dollars for a surgery. I don't understand why health insurance won't cover it. I understand why they wouldn't cover a breast enlargement, however, to reduce the size, it would benefit my health and well being. What am I supposed to do? I feel like I have no options.

Insurance companies do whatever they can to avoid their responsibility.  If your plan is via your employer, I suggest that your employee benfits office get involved to aid you in obtaining coverage.  Discuss your concerns with them, and if you are not able to resolve the issue, change insurance companies, as you have a medical problem.  You might also complain to your State insurance Department.

Darrick E. Antell, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

Insurance Problem in Petite Women

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Insurance coverage of breast reductions has long been diificult. I feel that petite women are at a disadvantage.  Make certain that your insurance policy does not have an outright exclusion for reductions.  If not, I have sometimes had success by involving state insurance commissioners.

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Insurance coverage of Breast Reduction - Don't give up!

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Dealing with insurance companies can be a daunting and intimidating experience for the individual patient. This is an instance where your doctor needs to go to bat for you to obtain the necessary authorization.

It begins with a letter documenting typical symptoms of neck and back pain, rash under the breasts, occasional numbness of the small finger, and bra strap grooving. Some insurance companies want to see evidence of failed medical management (physical therapy and/or NSAIDS).

Photographs and measurements as well as calculation of body surface area are other pieces of information are used to further support the case for reduction surgery.

There also needs to be an estimation of the amount of breast tissue to be removed. The "Schnur Scale" is a chart which correlates body surface area to the expected amount of tissue to be removed. If the doctor's estimation does not conform to this scale it can sometimes result in a preliminary rejection.

If after all this has been submitted and rejection still occurs, it is worthwhile requesting an appeal by a board certified plastic surgeon. Many companies have either an internist or a general surgeon review the requests and so requesting a specialist is often times helpful.

Lastly, surgeons who have an exclusively cosmetic practice may not have the billing structure and personnel in place to help you move through this process and aid you in contacting the right people in your plan.

Take heart, it is increasingly rare that a well documented case will be denied!

Best Regards, 

KC

Kirk A. Churukian, MD
Los Gatos Plastic Surgeon
5.0 out of 5 stars 2 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.