Will Insurance Allow Breast Reduction from F to D Cup?

I have always been large breasted and have always wanted a reduction. In the past 2 years, I have given birth to two children and breastfed. My youngest is now a year old and my breast have not returned to "normal" size. I am still wearing my maternity, size F bras. My back and neck hurt all day long. As I said earlier, I have always been large breasted. Will insurance allow me to be a size D, or must you go really small? Am I a good candidate for insurance to cover my breast reduction? I am 33 years old, 5'7", and 165 lbs.

Doctor Answers (13)

Breast reduction and insurance coverage

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Hi, insurance companies are notoriously difficult when it comes to coverage for a breast reduction. Every company has a different standard, but in general they want to see a minimum amount of tissue off per breast prior to agreeing to coverage. You look and sound like you would be a good candidate to be covered by most companies. I would suggest calling your insurance company to check their policy. When you see your surgeon, his or her office should be able to facilitate sending in the request for coverage. Make sure the insurance company sends you something in writing if they agree to cover the surgery; the last thing you want is a surprise bill after surgery. Good luck, /nsn.


New York Plastic Surgeon
4.0 out of 5 stars 5 reviews

Candidates for breast reduction

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Based on your height, weight, and breast size, you look like an excellent candidate for a breast reduction. Criteria differ but most insurances require 500 grams be removed from each side. This equates to one pound per side. What cup size this equates to is not possible to say.

Many plastic surgeons no longer work with insurance and as such are not constrained by these size restrictions so the reduction can be customized to the size you want and not just to achieve a weight reduction.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 49 reviews

Will insurance allow breast reduction from F to D cup?

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Hello! Thank you for your question.  It is a safe procedure, in which your plastic surgeon will reduce the amount of breast tissue, reshape your breasts, raise the nipple-areolar complex to its appropriate position (possibly making the size smaller, if needed), and ultimately ameliorate the possible complaints that you do have for the reason that you are having this procedure (e.g., neck/back pain, migraines, rashes/infections, shoulder grooving, etc).  Your complaints certainly sound as if you would be the ideal candidate for a breast reduction.  Cup size alone is not mandatory, but sometimes the amount of tissue removed - enough should be excised to ameliorate your complaints.

It would be in your best interest to have a mammogram prior to the procedure for screening prior to this procedure, as the architecture imaging of your breast will slightly change afterwards. Well known data exists that having a breast reduction will in fact lower your chance for developing breast cancer, simply because the amount of tissue will be less.

Consult with a board-certified plastic surgeon who will discuss the procedure with you, examine, and assist you in determining if this is the right procedure for you.  Voice your complaints - your insurance will likely require a detailed description of your history and complaints as well as photo and an estimate of how much tissue will be removed.  You should give a description of the therapies that you have done to ameliorate your complaints thus far.  Any other notes from other physicians is helpful.  It would also behoove you to discuss your issues yourself with your insurance carrier.  Hope that this helps!  Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

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Insurance coverage for breast reduction

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I find that there is a large amount of variability in breast size when patients say they wear an F-size bra.  It is best for you to consult with an expert plastic surgeon to accurately estimate the weight that you will remove with breast reduction surgery.

David Stoker, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 19 reviews

Insurance and breast reduction

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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

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 123 reviews

Breast reduction and insurance coverage

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I believe that every Plastic Surgeon would consider your request very appropriate considering your current breast size.  The decision rests with your insurance company, however, and this often is a challenge for the well deserving patient.    Always use the advise of your local Plastic Surgeon in trying to increase the possibilities for approval for your request.  You may be asked to try to lose some weight, engage in physical therapy or chiropractic care for a period of time to show that conservative measures have been considered.

 

If all else fails and it is not covered, be aware that you still can move forward with the operation and should expect a good result.

 

Good luck to you. 

 

Frank Rieger M.D.  Tampa Plastic Surgeon

Francis (Frank) William Rieger, MD
Tampa Plastic Surgeon
5.0 out of 5 stars 45 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 757 reviews

If breast reduction is performed to improve functionality by relieving pain in the

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neck, shoulders and back, or to relieve chronic infections where the breast meets the skin of the chest wall, then insurance may cover the procedure.  Often the insurance coverage will depend on how many grams of breast tissue are removed in the reduction, but you appear to be someone who would qualify on that basis.  Each insurance company has heir own criteria to determine coverage, and you will need to work with the plastic surgeon you consult with to obtain pre-approval for the surgery.  If you have seen another physician for symptoms related to your breast size, careful documentation of those encounters, as well as good "pre-operative" photographs, can help you obtain pre-approval for the surgery. 

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

Insurance coverage for breast reduction

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Each insurance company has different criteria for pre-approval of a breast reduction surgery and you should contact your carrier.

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

Insurance coverage for breast reduction.

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Insurance Coverage for Breast Reduction
View Edit

Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
Contact the doctor
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

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.