Breast Reduction Went Wrong: Will Insurance Cover a Revision?

I tried to have a breast reduction 14 years ago but the doctor did one side and let a resident do the other. It was a disaster and after two more surgeries he had put big implants in with one side much bigger than the other. They were never reduced.

They have gotten larger with age and I have had 10 back surgeries. Do you think the insurance will cover it. I am 5'7" 130 lbs and wear a 36-38 DD. My shoulders and upper back hurt all the time. I don't have the money to pay for it.

Doctor Answers (7)

Breast Revision and Insurance Coverage?

+1

Thank you for the question.

Unfortunately, there is no way of knowing what a specific insurance company will deem “medically necessary” and covered by their plan. It will be in your best interest to visit with a well experienced board-certified plastic surgeon who can approach the insurance company on your behalf. The more support you have from your other treating physicians the better.

Best wishes.


San Diego Plastic Surgeon
5.0 out of 5 stars 720 reviews

Is secondary surgery covered by insurance?

+1
Usually, if a breast reduction was covered by insurance, additional surgery to deal with complications would also be covered. However, your revisional surgery involved implants, which are, in most instances, not covered except for in breast reconstruction after mastectomy. The rule of thumb is that if the insurer paid for those implants, they will probably also pay for correction---unless your policy provisions have changed or their clinical guidelines have been modified since the time of the last surgery. From your posting, I haven't quite figured out how you went from a reduction for back pain to implants but the full history is something you can definitely discuss with a board certified plastic surgeon in consultation. I would recommend that you obtain a complete copy of your medical records from the initial treating doctor or, if he is no longer available, from the hospital at which the procedures were performed so that any plastic surgeon you see now can get the full picture. Good luck!

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

Maybe.....

+1

Hello,

 

While I feel for you and your situation, trying to predict what an insurance company will cover these days is difficult at best. Try to obtain pre-approval and hope for the best.

 

Best Regards,

 

John Di Saia MD

John P. Di Saia, MD
Orange Plastic Surgeon
5.0 out of 5 stars 23 reviews

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Breast Reduction - Will Insurance Cover a Secondary Reduction?

+1

Hi Maryannob

I'm obviously sorry for what you've been through and are going through.

There are many issues with respect to insurance.  Each insurance company is different, and each has its own rules with respect to "coverage."  You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

Either way, you'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.  In your case, having the history of back problems may be helpful in obtaining insurance company coverage, but you will still most likely need to have enough tissue removed for them to consider it and, based on your size, you may or may not then be happy with the final result.  You should, of course, meet with a few plastic surgeons to see what they recommend, and make sure you're informed about the procedure and its risks so that you can proceed knowledgeably.  If you do all of this you'll be most likely to have a result you'll be happy and comfortable with.

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.  In general, they are less likely to provide coverage if it's a question of correcting asymmetry; and more likely to the extent that the surgery can provide symptomatic relief of some kind.

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

Will insurance cover breast reduction surgery

+1

There is no easy answer to your question.  Based on your story, you do seem to be a good candidate.  However, it really is dependent on your insurance company and your doctor.  So, I would suggest working closely with your doctor and your insurance company to make sure that every effort is made to help get your surgery covered by insurance.

 

Good Luck.

David Shafer, MD
New York Plastic Surgeon
5.0 out of 5 stars 57 reviews

Your Insurance Should Cover Your Breast Reduction

+1

With your back surgeries and history of failed surgery I would think that your insurance would cover your breast reduction, lift, reconstruction, implant explantation.    Who is your carrier?  PPO?  HMO?  Consult with a Board Certified Plastic Surgeon in your area.  I suggest a member of the American Society of Aesthetic Surgeons and one who does many breast reductions a month.  Revision surgery of this kind can be trickey.   Good Luck!

Dr Grant Stevens

Grant Stevens, MD
Los Angeles Plastic Surgeon
4.5 out of 5 stars 67 reviews

Breast Reduction Problems

+1

Your history of problems is unfortunate.  The simple ansqwer is yes your insurance will cover .  If there is an argument be tough and if necessary get an attorney.  You will be covered by any  insurance.   Dr George Commons, MD

George Commons, MD
Palo Alto Plastic Surgeon
5.0 out of 5 stars 26 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.