How to Get Documentation for Breast Reduction Insurance?

In my past question, I was told I could go to a regular family doctor or a gynecologist to get documention for breast reduction insurance. How do I go about doing this? Do I need to request a letter or what?

Doctor Answers (15)

Insurance

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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


Houston Plastic Surgeon
4.5 out of 5 stars 114 reviews

Insurance Approval Documentation for Breast Reduction

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The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.

Your plastic surgeon will then contact your insurance company for preauthorization. 

Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria. 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.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 38 reviews

Breast Reduction and Insurance Coverage?

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Yes, the more letters you have from physicians, physical therapists,  and chiropractors etc. the better. It will behoove you to ask insurance company directly what their specific criteria are.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 682 reviews

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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

Documentation for breast reduction

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If you wish to have your breast reduction covered by your insurance company, start by calling them and asking them what information they need. Every company has different requirements. You will at least need a letter from your plastic surgeon requesting authorization for surgery, and a set of photographs (which your surgeon can take) for their review. Some insurance companies also want a letter from a chiropractor or orthopaedic surgeon documenting back, neck, or shoulder pain. Some also ask for a letter from a dermatologist if you have a rash beneath the breasts. But, before you spend a lot of time gathering letters, just call your company to see what their policy is. Good luck, /nsn.

Nina S. Naidu, MD, FACS
New York Plastic Surgeon
4.0 out of 5 stars 5 reviews

Breast reduction coverage

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Karim,

Insurance coverage for breast reduction surgery varies widely between no coverage at all and full coverage depending on the insurance carrier, the plan within the insurance carrier, the state you live in. Any documentation that you can provide to support your claim will improve your chances of getting coverage. That would include letters from family doctors, gynecologists and sometimes carriers even demand evaluation by an orthopedic surgeon. Good luck!

Kenneth R. Francis, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 31 reviews

Documentation for insurance coverage of breast reduction

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Hi,

Insurance companies require specific documentation from plastic surgeons prior to approving reduction mammaplasty. This usually includes photographs demonstrating large breasts and shoulder grooving from bra straps, as well as a letter describing patient's symptoms, other treatment modalities attempted, and the estimated amount of tissue that will be removed.

Supporting documentation from other physicians and health care professionals can be very helpful in facilitating the approval process. Letters from physical therapists and chiropractors documenting failed therapy for back pain and neck pain, as well as from primary care doctors demonstrating neck pain, shoulder pain and heat rashes despite appropriate use of a support bra, all help immensely.

Hope this helps. Best of luck.

Sam Jejurikar, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 27 reviews

Insurance coverage for breasts

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 If you have symptomatic macromastia because of large breasts and this can be documented by your internist, orthopedist, or chiropractor, you may be able to get coverage.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 15 reviews

Breast reduction documentation

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Any time you go to see a doctor, they bill your insurance company. When they submit a bill they use a code to describe the reason for your visit. This gets logged into a database called the Medical Information Bureau (MIB). Soi if you make a breast reduction the main reason for your visit. It will automatically be filed under your insurance. You can also request that your physician(s) write a letter of support.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 41 reviews

Insurance for breast reduction

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Most insurances require several things to cover breast reductions

1. Large breasts

2. Symptoms preferably documented by other healthcare providers, especially orthopedic doctors, chiropracters, physical therapists

3. Trials at non surgical treatment, proper bra support, physical therapy, etc

4. Removal of a certain amt of breast tissue (often based on the body mass index)

If you are rejected and you feel you have all these bases covered follow the appeal process

John P. Stratis, MD
Harrisburg Plastic Surgeon
4.5 out of 5 stars 14 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.