I Am About 5"8 and Weigh 180. My Breast Size is a DDD or G. Will Insurance Pay for Reduction?

I have Blue Cross and need to know if it likely that they would say I have enough tissue that could be taken out for them to cover this as a medical problem

Doctor Answers 8

Will insurance cover your breast reduction?

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

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Breast Reduction - Insurance Coverage

Maybe.

There are many issues with respect to insurance.  Each insurance company is different, and each has its own rules with respect to "coverage."  You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

Either way, you'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life).

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.

I hope that this helps, and good luck,

Dr. E

Insurance will pay for breast reduction surgery, but must meet requirements

Document, document, document! Insurance companies will pay for a breast reduction IF the woman has neck, back, shoulder or breast pain, or rashes or macerations that require medical treatment.  They determine the amount to be remove based on body surface area.  You would have to contact BCBS for their requirements.  The disadvantage of having your insurance company pay for the procedure is meeting their weight requirements.  For example, if the weight requirements were 600 grams, you would go down 3 cup sizes and that would make you a C cup.  This may not look good to you and you may not be satisfied with the result.  In that case, you would be better off paying a plastic surgeon to reduce your breasts the way YOU want, rather that what the insurance company demands.

Best of Luck,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 153 reviews

Breast Reduction Insurance

Insurance may cover breast reduction for some women. It depends on the patient’s breast size, body type, and symptoms. Most insurance companies have a formula based on your height, your weight, and how much your surgeon estimates will be removed. Usually removal of about a pound from each breast is required for insurance coverage.  Health care providers are mercenary about denying coverage for breast reduction. They don’t care if your clothes don’t fit or you can’t exercise. In my experience, they don’t even care about your pain and discomfort, much less psychological embarrassment. It all boils down to your height and weight versus how much breast tissue will be removed. You can’t necessarily pick your desired breast size or shape. To remove less than the insurance company’s formula requires places the procedure in the realm of cosmetic surgery. That means you pay the bill. Your surgeon should get a detailed medical history because some health- care providers demand a history of treatment for back pain to authorize coverage. I measure the breasts and often take photographs to be mailed with the insurance letter. If I don’t comply with the rules, the insurance provider— who holds all the cards—may not authorize paying for the procedure.  All the best of luck with this, "Dr. Joe" Gryskiewicz

 

Blue Cross Blue Shield May Cover Breast Reduction Surgery

You are most likely a good candidate for breast reduction surgery. Getting insurance to cover it is another matter. Most insurance companies have several different types of policies so it is possible some Blue Cross policies will cover while other may not. You should see a Board Certified Plastic Surgeon who can tell you if you would qualify and then would help you get preauthorization.Good luck!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.5 out of 5 stars 39 reviews

Will Insurance Pay for Breast Reduction

You should be able to be considered for a breast reduction if you meet certain criteria. Call a Board Certified plastic surgeon or get a referral from your primary care doctor.


You may want to ask the surgeon's office ahead of time if there is anything else they would like you to bring (insurance information, name of primary care physician). For breast reduction surgery, it would be good to find out what criteria your insurance company requires to approve the surgery and have it available at the time of consultation. This includes:

Symptoms such as neck, back, shoulder pain, headaches, hand numbness, breast pain, rashes under the breasts, poor posture. Documentation from your primary care doctor of these symptoms Documentation that you tried 6 months of physical therapy to improve these symptoms Other requirements based on your insurance company's protocol Results of your last mammogram or other breast studies (if you had any)

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
5.0 out of 5 stars 27 reviews

Breasts Reduction and Insurance Coverage?

 Based on your description you may be a good candidate for breast reduction surgery; it is one of the most patient pleasing operations we perform. If you are not there you may want to reach a long-term stable weight prior to surgery.

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.  

 Prepare to be persistent.

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.