Am I a Good Candidate to Get Insurance for Breast Reduction?

im 21, I weigh 160, I'm 5'4 & I'm a 32h. I'm usually 125-140 & 32g. But since I gained weight so did my breasts. I can't lift my arms for more than a minute w/o complaining of back pains. I have back pain now & I'm bra not wearing a bra. My shoulders have huge indentations & the area under my breast have dark marks from the bra. I'm planning on losing 15 lbs & getting a reduction by end of summer. My step dad has me under his insurance, united health care choice plus. What are my chances?

Doctor Answers (9)

Insurance Candidate for Breast Reduction

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Sounds like you are a good candidate for Breast Reduction. . 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.


Orange County Plastic Surgeon
5.0 out of 5 stars 45 reviews

Am I a good candidate to get insurance for breast reduction?

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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).

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

Insurance coverage for 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

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Coverage for Breast Reduction

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  • Meet with a board certified plastic surgeon who can examine you carefully.  He or she will be able to better counsel you on the chances that insurance will cover a breast reduction.   Additionally, he or she may write a letter to your insurance company on your behalf to seek pre-authorization. 
  • Every insurance company has its own set of criteria that have to be met including: amount of tissue that should be removed based on your height and weight, documentation of symptoms, and documentation that therapies such as physical therapy or massage therapy have failed to improve your symptoms. 
  • From your description, it sounds that you may be a good candidate to undergo a breast reduction. 
  • Best of luck to you!

Joshua Cooper, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 14 reviews

Breast Reduction and Insurance

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You sound like a good candidate for insurance coverage. Each insurance company has their own requirements that you need to meet. Most say you need to have a minimum of 500 grams removed from each breast, and documentation of what you have tried in the past for relief such as; good support bras, physical therapy and analgesics. See a board certified plastic surgeon that specializes in breast reduction surgery and your surgeon will know how to help you request coverage from your insurance. Good luck!

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon
4.5 out of 5 stars 30 reviews

Breast reduction and insurance

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It is quite possible that you can have insurnace cover your procedure. You may need to find out their criteria and then see a surgeon. Good luck.

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

Breast Reduction Candidate?

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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.
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.  You will find that every insurance has its own specific “criteria” for the amount of breast tissue that must be removed; you will need to check with your insurance company for precise information.
Before undergoing the breast reduction procedure it will be very important to communicate your size goals with your surgeon.  Most patients wish to achieve a enough of a reduction to help with their symptoms while remaining proportionate with the remainder of their torso. 
With the goal of improving communication with my patients I find the use of photographs of “goal” pictures (and breasts that are too big or too small)  very helpful. I have found that the use of words such as “natural” or “C cup” etc means different things to different people and therefore prove unhelpful. 
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.
Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 751 reviews

Insurance coverage for breast reduction

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Yes, you meet all the criteria but one---you must establish that conservative medical management (ie-chiropractic, physical therapy, etc.) has been unavailing for at least three months. If you start on PT right now and have your plastic surgeon submit the preauthorization to United by early August, expect the approval to take anywhere from 4-6 weeks.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 12 reviews

Good candidate for breast reduction

+1

Hi - before considering a breast reduction, you can do some things to optimize your results. Make sure you are at a steady weight, and that you are certain your breasts have mostly stopped growing. Breasts usually stop their growth curve in your early '20s, so you are nearly there. Also, think about whether or not breastfeeding future children is a priority for you, as a reduction may affect your ability to breastfeed. Lastly, make sure you see a Board Certified Plastic Surgeon. A lot of women are very happy after a breast reduction, and share similar pre-operative complaints as you describe. Without examining you, it is hard to tell if insurance will cover your reduction, but I think there is a good chance given your height, weight and breast size measurements. Best of luck with your endeavor!

Tracy Kadkhodayan, MD
Minneapolis Plastic Surgeon
5.0 out of 5 stars 4 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.