Would I Be Approved for Breast Reduction Surgery if I Am 5"0 210lbs 48f Bra Size?

Hi! Im 31 5"0 210 with a 46 to 48f bra size. I was denied last year for br because of my BMI, but i have explained to my PCP that in order for me to exercise properly, i would really need the surgery. I have United Healthcare now but im afraid they wouldnt consider the surgery medically necessary. I have severe back pain/neck pain issues and pinched nerves due to having large breasts and my posture is out of place. I really need this surgery!!

Doctor Answers (9)

Breast reduction insurance approval

+2

Thank you for this important question.  I have no doubt that you could get symptomatic improvement with breast reduction surgery.  And, documenting your breast size and the symptoms you have is important.  Unfortunately, your current BMI is 41 and, in my experience, insurance will often decline breast reduction requests in that BMI range.  I suppose the assumption is that weight reduction would likely result in some reduction of breast size.  Keep in mind that your risk of wound healing issues with this surgery also goes up with a BMI of 35 or more.  So, it would be in your best interest overall to pursue weight reduction first.  I understand the frustration.  Exercise can be so difficult.  A few of my patients have pursued light exercise regimens in conjunction with physician guided portion and calorie controlled diets and have been successful.  When their BMI gets into a more safe range and their breast size remains large, we resubmit the new details and they frequently get approved.  If you have failed weight reduction attempts in the past, you and your primary doc may consider researching weight loss surgeries such as gastric bypass and the lap band.  I know that those options can seem extreme, but I highly recommend going to an informational session often offered by bariatric surgeons in your community to learn more.  That type of surgery is more life changing than breast reduction and can make many medical problems (such as high blood pressure or early diabetes) disappear in a matter of weeks in addition to the weight.  It sounds like you are a motivated patient to get good care for yourself.  I definitely encourage you to pursue it all.  Good luck!     


Austin Plastic Surgeon
5.0 out of 5 stars 7 reviews

Breast Reduction - Would I Be Approved for Breast Reduction Surgery if I Am 5"0 210lbs 48f Bra Size?

+1

Good question, but no plastic surgeon can answer this for you.  Whether or not this, or any other, procedure is "covered" by insurance depends on specifics of your insurance policy.  Two people who have the same shape and size may be treated differently depending on their insurance policies (one may be approved; the other denied).

The best way to approach this is to have your plastic surgeon contact your insurance company on your behalf (you can do this on your own, also) and to find out what the criteria are for approval.  In the event that there is an outright denial, you can appeal the decision, based on exactly the issues you're talking about (persistent back pain, etc.). 

Getting approval can not be guaranteed but being persistent may help sway the outcome.

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 150 reviews

Breast reduction approval

+1
If United categorizes you as having gigantomastia, then the weight would not be a factor. In 2010, United changed its criteria to require that patients prove that the size of the breasts interferes with activities of daily living. If you have documentation of back/neck issues, including neuropathy, then they may approve the surgery regardless of your BMI. It's important for you to obtain a referral to see a board certified plastic surgeon as I find, as a rule, that internists are clueless as to the actual insurance requirements for approval.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 11 reviews

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Breast reduction

+1

Each insurance company has different criteria regarding BMI and breast reduction approval. You should call your insurance company and find out their policy.

Steven Wallach, MD
Manhattan Plastic Surgeon
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Insurance for Breast Reduction

+1

Unfortunately you are asking your question of the wrong people. We know there is no question at all that your surgery is medically necessary. You would have a major and lifelong benefit. But whether or not your insurance company covers it is up to them. Remember the insurance company is in business to make money. They make money when you pay them, not when they pay you. Their arrangement with you is contractual and clearly spelled out. You may need to seek a new health carrier, or as more than half of my reduction patients do, just pay for the surgery and be done with it. BTW..I see many women who have the surgery and are so excited and pleased with their new shape that they become much more aggressive with exercise and diet to continue to improve after the surgery.

 

Good Luck.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 13 reviews

Insurance coverage for breast reduction.

+1

Hi.  I hope you find this article useful.  Good luck!

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

Breast Reduction and Insurance Coverage?

+1

Thank you for the question.

No doubt you will be an excellent candidate for breast reduction surgery; it is one of the most patient pleasing operations we perform. As you know, timing of the surgery is patient specific; ideally, it is best done when a patient is as close as possible to a long-term stable weight.

Unfortunately,  there is no way of knowing whether your procedure will be covered by the insurance company,  except for directly contacting them. Your plastic surgeon will be able to contact them on your behalf as well. The more support you have for the “medical necessity” of the procedure the better.

Prepare to be persistent.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 716 reviews

Breast Reduction and Insurance

+1

Different insurance companies have different criteria for approval for breast reduction surgery. You might try seeing a plastic surgeon and have him or her try to get approval for you. Surgeons are very familiar with the process and may have better luck. However, if you are turned down again ask your surgeon to request an appeal. Many times an approval will come through on appeal as a doctor for the insurance company will contact your surgeon and get more detailed information specific to your case. Good luck!

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon
4.5 out of 5 stars 29 reviews

Breast Reduction: Getting Insurance Approval, what are the criteria?

+1

Breast Reduction Surgery is one of the highest satisfaction procedures that plastic surgeons perform.  Patients often present with significant symptoms that result from the heavy, pendulous nature of the breasts.  Some of these symptoms are neck, back and shoulder pain, knee problems, rashes and shoulder grooving.  Surgical reduction does more than create beautiful, balanced sensual shape; it relieves the chronic symptoms almost immediately. 

Insurance companies often use criteria, which do not accurately asses a patient's need for breast reduction, to determine eligibility for this surgery.  If your plastic surgeon demonstrates that your symptoms are significant and have not been improved with non-surgical methods, and that your expected weight of breast reduction meets a certain scale, then your insurance should cover the procedure.  Don't give up, you are the consumer for the health insurance coverage and are entitled to treatment.

John G. Apostolides, MD, FACS
La Jolla Plastic Surgeon
5.0 out of 5 stars 12 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.