Will my Insurance Cover Breast Reduction and Tummy Tuck?

Dear Dr.,

I am a mother of 4 and even though I eat healthy food and exercise 5 times a week, I am not able to lose the weight. I have been considering Lipo and Tummy Tuck.

I also have large breast (38DD) which causes me to get rashes between the breast and the ribcage. I also get constant back aches and shoulder pains. I'm thinking about Breast Reduction, too. Will my insurance pay for these procedures or at least part of the procedures? Thanks.

Doctor Answers (13)

Insurance Coverage: Breast Reduction- sometimes, Tummy Tuck - No

+1
A tummy tuck is not covered by insurance and considered a cosmetic procedure. Under certain circumstances Breast Reduction is covered by insurance. Unfortunately, each insurance company has their own criteria. 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 through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses


Orange County Plastic Surgeon
5.0 out of 5 stars 50 reviews

Insurance coverage for breast reduction

+1

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 128 reviews

Insurance coverage for breast reduction

+1

Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.

Sugene Kim, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 40 reviews

You might also like...

Breast Reduction and Tummy Tuck - Insurance Coverage

+1

Good question!  In general, insurance coverage for breast reduction may be available depending on how much breast tissue is being removed (it's actually a function of that, plus your height, weight and any mitigating medical or health issues...each insurance company has its own criteria).  However, if you are a 38 DD then you may not be happy if enough tissue is removed to satisfy the insurance requirements (ie, you may then be too small).  That's something you'll have to discuss with your plastic surgeon.  And I think it is unlikely that you will obtain insurance coverage for any services (surgery, anesthesia, etc) related to your tummy tuck which, in the absence of a documented hernia or massive weight loss with subsequent chafing and irritation, is generally considered a cosmetic procedure.

I hope that this helps and good luck,

Dr. E

Alan M. Engler, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 155 reviews

Breast Reduction, Tummy Tuck and Insurance Coverage?

+1

Thank you for the question.

You will have a much better chance with the insurance company covering the breast reduction surgery as opposed to the tummy tuck surgery.

Consultation with a well experienced board-certified plastic surgeon will be helpful.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 791 reviews

Breast reduction and insurance coverage

+1

Dear Izzie, your insurance company will probably cover the breast reduction.  Your doctor will probaly have to submit your photos and an explaination of your symptoms to them and get preauthorization prior to your surgery.  Unfortunately, they usually will not cover tummy tucks.

Vincent D. Lepore, MD
San Jose Plastic Surgeon
5.0 out of 5 stars 20 reviews

Insurance Coverage for Breast Reduction and Abdominoplasty

+1

We have had much success with insurance coverage for breast reductions for patient who have pain and rashes due to the size of their breasts. Often times, the insurance company will ask that the patient seek conservative treatment prior to insurance approval. Conservative treatment may include wide strapped bras, over the counter medications, chiropractic visits, etc. It is best to check your specific insurance plan to determine if breast reduction coverage may be available. the second step is to consult with a board certified plastic surgeon for an evaluation. Insurance companies typically will view the abdominoplasty as a cosmetic procedure and deny coverage. Your plastic surgeon's office should be able to assist you in communication with your insurance company. Best wishes! 

Christine Sullivan, MD
Columbus Plastic Surgeon
5.0 out of 5 stars 22 reviews

Breast reduction and tummy tuck insurance coverage

+1

You will probably have more success seeking coverage for the breast reduction. Insurance companies wil not cover abdominoplasty surgery unless you underwent gastric bypass surgery and had massive weight loss with an overhanging pannus. They may cover the pannus removal and not the muscle tightening or umbilicus repositioning. And this is only for a handful of patients.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

Insurance coverage for breast reduction.

+1

Insurance Coverage for Breast Reduction

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

Insurance will not cover Breast Reduction and Tummy Tuck

+1

No.

No insurance company that I know will cover BOTH a tummy tuck (a cosmetic surgery) and breast reduction (each company has different criteria for what they cover).

IF you policy has "BREAST REDUCTION BENEFITS" it MAY pay for your surgery PROVIDING the surgeon (who must be a "participating" plastic surgeon -- not all of us "participate" will all plans) removes a pre-set weight of breast from each side. Since each company differs, I would suggest that IF you DO have breast reduction benefits with a certain policy - that you see one of its surgeons to see what he/she thinks as well as see if he/she would like to do your tummy tuck at the same time.

Be prepared. Some surgeons would decline to do it for fear that the insurance company may refuse to pay the breast reduction component claiming the WHOLE operation was cosmetic.

I hope this was helpful.

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 66 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.