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Am I Big Enough to Qualify for a Reduction (Via Insurance)? (photo)

I'm 5'5, 142 lb, 39 years old. I wear a 36DDD (fitted at a local bra shop). I am not having any more children. I am suffering from awful backaches - I am seeing a chiro (had to break down to do it because I'm in agony!). I looked at the UHC schnor scale and I think I would need at least 404g removed per breast. I would love to be a C (golf, running, etc.) I'm also pretty lopsided - one side is 1 cup size larger? Does it sound like I have enough to remove?

Doctor Answers (13)

Qualifying for breast reduction

+2

You may indeed qualify, but we have all misjudged size based on photos and an exam with a board certified plastic surgeon who frequently performs breast reduction surgery is the best way to get started.  Then, if you seem in range to get insurance coverage, a letter is written to your insurance with all the proper documentation to try to get you the best chance of obtaining pre-authorization for the procedure.  I hope you look into it further.  It is one of the surgeries we offer with the highest level of patient satisfaction.


Austin Plastic Surgeon
5.0 out of 5 stars 7 reviews

Insurance coverage for Breast Reduction

+2

If you are having back pain from large breasts, your insurance should cover the procedure; however, it will depend on your insurance. After fighting the coverage for Breast Reduction for years, some insurance companies have started to exclude Breast Reduction as a covered procedure in all circumstances. Others have set minimum weight limits for the excision, and will only allow surgery after certain qualifications have been met like weight loss, trial of physical therapy and documentation that other treatments have been tried.

 

For women with truly symptomatic macromastia (large breasts) non-surgical treatment is usually not helpful. You will need to read your insurance policy to see if you are eligble for the procedure, and if so, the best way to get your question answered it to schedule a consultation appointment with a Board Certified Plastic Surgeon and have them submit a request for prior authorization.

 

My Breast Reduction  patients are some of my most grateful, so I hope you find relief. Good luck, and hope you are feeling better soon.

Joseph Mele, MD
Walnut Creek Plastic Surgeon
5.0 out of 5 stars 6 reviews

Insurance coverage

+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 115 reviews

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You may qualify but not get the desired outcome

+1

At 36 DDD each cup size is 200 grams.  If you are going down 2 cup sizes (400 grams) you would be a D.  However, the surgeon could take off more.  600 grams would make you a C if that is what you desired.  Insurance companies base approval on 2 factors.  First, you must have symptoms related to the large breasts such as neck, back and shoulder pain or rashes.  Second, you must meet their weight criteria (which you say is 404 grams), which you should easily meet.  However, one you your goals is to be pain free.  You can achieve pain relief without excessive reduction.  There is a new technique that transfers the weight of your breast to the underlying muscle to achieve pain relief.  This technique also avoids the ugly vertical scars such as the boat anchor shaped incisions.  You are an excellent candidate for a new technique called The Ultimate Breast Reduction.

Best Wishes,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 123 reviews

Qualifying for Breast Reduction Surgery

+1

Based on your dimensions, photo, and symptoms, you appear to be a candidate for breast reduction surgery. If your primary care physician provides documentation and treatment of your symptoms arising from your breast hypertrophy, you should be able to have insurance pay for breast reduction surgery. If you are approved by insurance, you could then be evaluated by a plastic surgeon for surgical treatment. With a proper evaluation, your  plastic surgeon will be able to estimate if a 404 gram resection is possible. Your surgeon will also go over the pros and cons of having breast reduction surgery.

Surgery will be able to create better volume and shape symmetry. Reducing the size and weight of the breasts does make a huge difference in back pain. If you are finding it difficult to exercise, it does become easier and much more enjoyable without carrying all the extra weight on your chest.
Thank you for your question. Best of luck!

 

Gregory C. Park, M.D.

Gregory Park, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 51 reviews

Enough breast tissue for a breast reduction.

+1

By your photos and description you may be a good candidate for breast reduction. It is a bit difficult to say for sure without a physical examination as some breast tissue is more dense (thus heavier) than others. Insurance coverage is discussed well by other responses to your question on this site. I would encourage you to meet with a qualified plastic surgery to discuss your concerns and have a personal physical examination.

Brian J. Lee, MD
Fort Wayne Plastic Surgeon
5.0 out of 5 stars 7 reviews

Insurance Coverage for Breast Reduction - "It Depends"

+1

Insurance coverage is NOT a simple entity. Instead, just like all restaurants (in principle) serve food but each has different items on their menues, each commercial insurance company sells MANY DIFFERENT policies (dishes). Some obviously cost more than others. It is therefore a mistake to ASSUME that just because several people went to restaurant X - they all had the exact food.

To make things MORE difficult, just like certain dishes contain certain ingredients that others do not - certain policies may or may not "COVER" certain procedures or conditions including Breast Reduction surgery. (It makes NO DIFFERENCE if you could benefit from the procedure or not. If your policy does not include it, you did not pay for this procedure and it will not be paid for by the insurance company). And among those policies who DO include it, many insist that a certain Y amount of breast tissue weight be removed from each side for them to pay the medical bills of the operation AFTER (and IF) they approve it.The amount varies in my area from 500 grams(1.1 pound) to 1,000 grams (2.2 pounds) PER SIDE.

Since Bra Cup size is NOT a universally standard which is easily translatable into weight NO ethical surgeon can assure you that the removal of 500 grams or more would certainly result in an X bra cup size. When they do so they are always guessing and estimating.

i would look up several Plastic surgeons in your community who accept your insurance AFTER you verified you do have Breast reduction coverage. Based on their experience with your insurer they could advise you how much needs to be taken and what size breast you may end up with.

If your insurer does not cover it/ if you do not wish to lose as much weight as your insurance wants to be taken off and if you want your surgeon to remove more from the larger side to try and get the breasts to be as close in size to one another you may want to pay for this procedure out of pocket.

Peter A Aldea, MD
Memphis, TN

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 59 reviews

Breast Reduction through Insurance

+1

Insurance will often cover breast reduction when there are symptoms associated with large breasts. These include back pain, neck pain, shoulder grooving from the bra strap, shoulder pain, paresthesias, and recurrent breast rashes. Insurances expect a certain amount of reduction depending on your height and weight for them to approve. A full consultation with a board certified plastic surgeon and insurance predetermination are required.

Frank Agullo, MD
El Paso Plastic Surgeon
5.0 out of 5 stars 28 reviews

Am I Big Enough to Qualify for a Reduction (Via Insurance)?

+1

It depends on so many variables. Like what health insurance plan? Write a "pre determination letter to your health insurance company. Obtain a mammogram ASAP. Than see if you are considered a qualified candidate. Good luck. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 61 reviews

Breast Reduction and Insurance Coverage?

+1

Thank you for the question and picture.

 As you know, it is not possible to give you precise advice without direct examination. Your best bet would be to meet with well experienced board-certified plastic surgeons;  asked to see lots of examples of their work.

My initial impression evaluating your picture is that you may be left with breasts that are too small ( proportionality wise)  if  enough tissue is removed to satisfy health insurance company requirements.

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.

Regardless of how you choose to proceed you should be aware that breast reduction surgery is one of the most patient pleasing operations we perform.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 703 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.