I Am 5'5" & 165 Lbs with 38DDD/F Breasts. Would Insurance Cover Breast Reduction Surgery? (photo)

Am I a good candidate for breast reduction surgery? Would insurance be likely to cover it?

Doctor Answers (10)

Insurance Coverage for excessively large breasts

+1

I would think that you would be a good candidate for Breast Reduction and would be approved by many insurance companies.

Here are some helpful information:

Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company.  In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc. They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems.. Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.

Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth).  In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities.  Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month.  Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance though insurance criteria are becoming more and more restrictive


Orange County Plastic Surgeon
5.0 out of 5 stars 47 reviews

Body Surface Area determines Breast Reduction criteria

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Insurance companies will base breast reduction authorization on body surface area.  According to your height and weight, I have calculated your body surface area to be 1.85 meters squared.  According to the Aetna protocol, this will require a removal of 715 grams, which corresponds to 3 1/2 cup reduction.  The result would be approximately a 38 C.  Depending on your desire, a 38 C may not be acceptable to you.  Your alternative would be to pay for the procedure yourself and get the size that your desire.

Best of Luck,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 127 reviews

Breast reduction surgery

+1

From your photographs it appears that you would be a reasonable candidate for a breast reduction.  In most cases this would be covered by insurance but it will differ depending upon your policy.  

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

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Breast reduction and insurance

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It is quite possible that insurance could cover your breast reduction. Each insurance company has different criteria and you  may want to investigate what they want.  It is best to go for a consultation as well. Good luck.

Steven Wallach, MD
Manhattan Plastic Surgeon
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Breast reduction coverage

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You are an excellent candidate for surgery based on the size of your breasts and your reasonable weight. Each insurance company has its own protocol and requirements for preauthorization of benefits. Some require conservative medical management, such as physical therapy, chiropractic and documentation of no underlying spinal pathology. Others have much easier guidelines. You should look at your insurance company's criteria, which should be available on its website, for more information and then see a board certified plastic surgeon for a consultation.

Robert L. Kraft, MD
New York Plastic Surgeon
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Breast Reduction and Insurance Coverage

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It appears that you would be an excellent candidate for breast reduction surgery. Your best course of action would be to see a Board Certified Plastic Surgeon that specializes in breast reduction surgery. Your surgeon will know how to approach your insurance to help you get coverage. Different insurance companies have different criteria. Most require that you will need a minimum of 500 grams of breast tissue removed from each breast. Then the insurance company will want documented proof of what you have tried so far, such as physical therapy, good support bras, etc. If you get turned down the first time, request an appeal, I have had several patients win on appeal. Good luck! 

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon
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Insurance Coverage Of Breast Reduction

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The only way to know for sure if your reduction will be covered is to see a plastic surgeon who can then communicate with the ins. co. to determine prior approval.  Some insurance cos. insist on PT, chiropractics, or other conservative treatment and some have outright refusals to cover reduction in policy.  Most look at symptoms and amount of tissue to be removed in relation to BSA.

John Whitt, MD
Louisville Plastic Surgeon
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I Am 5'5" & 165 Lbs with 38DDD/F Breasts. Would Insurance Cover Breast Reduction Surgery? (photo)

+1

Yes you SHOULD be covered but every insurance has restrictions. Best to see a boarded PSs in your insurance plan and obtain a letter of predetermination. Good luck. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 64 reviews

Inusrance Coverage of Breast Reduction Surgery

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Breast reduction surgery often causes significant symptoms of neck, shoulder, and back pain.  When patients have symptomatic mammary hypertrophy (large breasts), various insurance companies often have guidelines for the amount of breast tissue that must be removed for the surgery to be considered medically necessary.  During your consultation, your surgeon will review your medical history and perform a physical exam (which includes taking certain body measurements) to determine if breast reduction surgery is medically necessary for you.  There is no way to be sure based only on the picture alone, but I would recommend you visit a Plastic Surgeon certified by the American Board of Plastic Surgery for an evaluation.

 

Marcus Crawford, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 4 reviews

Breast Reduction Candidate?

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Thank you for the question and pictures.

Based on your pictures alone,  I think you may be an excellent candidate for breast reduction surgery. It is very likely that your breasts cause problems such as neck, back, and shoulder discomfort. They may significantly interfere with activities of daily living.

Unfortunately,  there is no way of knowing whether your procedure will be covered by your insurance company,  except for directly contacting them. 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.Your plastic surgeon will be able to contact them on your behalf as well. The more support you have for the “medical necessity” of the procedure the better.

Prepare to be persistent;  it will be worth it.  Breast reduction surgery is one of the most patient pleasing operations we perform.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 759 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.