Insurance Companies and Hospitals That Cover Breast Reduction?

I would like to know what insurance covers breast reduction and which hospitals? I am 20 years old, my weight is 148lbs. 5"3, and im a 42DD.

Doctor Answers (9)

Breast Reduction and Insurance Coverage?

+1

Thank you for the question.

It will  probably be easiest for you to check with your local community hospitals regarding insurance companies that typically cover breast reduction surgery. You'll be able to check each insurance companies policies prior to applying for the insurance company coverage. Be prepared to be persistent with  insurance companies;  their criteria for breast election coverage seem to become more strict  all the time.

Best wishes.

 


San Diego Plastic Surgeon
5.0 out of 5 stars 710 reviews

Insurance coverage for breast reduction.

+1

First, check with your insurance provider to see if they cover breast reduction surgery at all, and if so, what the criteria for coverage are. These will be listed in your information packet, or will be available if you ask. For most insurance companies, these criteria are now quite similar, and most are based on your height and weight (not just subjective complaints of back pain, neck pain, bra strap grooves, rashes under the breasts, and possible numbness from bra strap pressure on brachial plexus nerves).

There is a formula that your chosen plastic surgeon will use to determine if the amount of tissue you want removed will qualify for insurance reimbursement, or if the amount of tissue removal mandated by your insurance company will leave you too small. Your surgeon should be able to tell you this BEFORE surgery, and you should not assume that coverage will be automatic unless you are willing to be "too small" after the required amount of breast tissue is removed (or be "the requested size" and end up being responsible for the entire bill out-of-pocket since the mandated amount was not removed).

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
5.0 out of 5 stars 118 reviews

Insurance and breast reduction

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Each insurance company criteria for approval of a breast reduction varies. If you do not have insurance, call some insurance companies to find out their policy.

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

Insurance coverage for breast reduction

+1

Our breast reduction patients are some of our happiest patients. They appreciate their new look and literally have had a significant weight taken off their shoulders. As you know, some insurance policies may cover this procedure. However, it depends on the insurance policy and the insurance company. In our practice, we have seen many insurance companies do everything possible to avoid paying for medically necessary procedures such as a breast reduction. If you are not able to have your breast reduction covered by an insurance company, work with a board-certified plastic surgeon who has a great deal of experience in breast reduction and breast contouring and inquire about financing plans. In our practice, our patient coordinators are experts at finding a plan that will fit the patient's budget.
 

Pat Pazmino, MD
Miami Plastic Surgeon
4.5 out of 5 stars 65 reviews

Insurance coverage for breast reduction.

+1

Insurance Coverage for Breast Reduction

Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
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 coverage and breast reduction

+1

Most insurances will cover breast reduction although there has been a growing trend not to do that. Also, each has its own criteria for which coverage is allowed. If you have insurance that covers a reduction and if you meet their criteria, you will be able to bill the surgery through the insurance for the facility and for the surgeon if the surgeon takes insurance.

Please realize that many of the more experienced surgeons are no longer taking insurance because they only pay a tiny fraction of the real cost to do the surgery. In my own situation, doing a breast reduction that takes 3 hours or so, I unfortunately couldn't break even and pay my expenses if I took insurance.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 48 reviews

Insurance Coverage for Breast Reduction

+1

Most insurance companies cover breast reduction procedures. The criteria for each insurance company varies widely. Most companies consider your weight, height, breast size, anticipated amount of tissue that will be removed and any musculoskeletal symptoms you may have. If you have insurance, the first step is to contact your insurer and ask what their coverage criteria are. They can also tell you which hospitals and physicians participate in your health care plan.

James H. Schmidt, MD
Sarasota Plastic Surgeon
5.0 out of 5 stars 5 reviews

Many insurance companies cover breast reduction

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Sindy,

We have thousands of insurance companies in the US. Because of stringent underwriting rules, NY has less insurance companies than other states but the number will be in the hundreds.

To complicate matters, the insurance game resembles a poker game. Much like holding cards, each hospital or hospital group negotiates yearly which set of insurance plans (cards) it will work with and which it will stop taking. Doctors for their part review the benefits and often which insurance companies cause less hassles and decide which ones they will work with. This changes all the time.

If you ALREADY have insurance - open your brochure and:

1. check if your plans pays for breast reduction (a lot of them do NOT). Once you are certain that your insurance does pay for it, then ask yourself

2. which Plastic surgeon do you want to go to? Again, your book will have the latest listing of doctors who agreed to work with your insurer. Make a list of 3-4 of them, check them out at www.PlasticSurgery.org and then call their offices, check they take your insurance and then go and meet them.

3. Ask each one of them which hospital or facility in the Greater NY THEY prefer to operate in and have the doctor's office check that that facility takes your insurance.

Your are done.

If you do not have insurance. Things are more complicated since your coverage will depend on your employer's policy OR the policy you buy. But, it all comes back to having a policy which PAYS for breast Reductions. If it does not, you will have to pay out of pocket.

I hope this helped.

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 60 reviews

Insurance Coverage of Breast Reduction

+1

Most insurance companies would probably cover your reduction.  They usually look at the symptoms in relation to your body weight and the estimate of tissue to be removed.  You can check the ASPS and ASAPS websites for a board-certified plastic surgeon in the NYC area.

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 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.