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Breast Reduction and Lift Insurance Coverage Requirements?

I am a healthy 28-year-old. I was a 34 DD before having kids. I am 5'3" and weigh 150 lbs. I have 10 more lbs to go before I meet with a surgeon. My breasts used to be firm, perky and although large, very nice. Now they are saggy, huge and limp.

I would like to get a breast lift and breast reduction. I have BCBS of NJ, but live in Las Vegas. I will be done nursing in March. They are now larger than a 36F. Whats the next step? I want to be a 34 large C. I am wearing pink in the photo.

Doctor Answers (20)

Insurance coverage for breast reduction.

+6

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.


Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast reduction by insurance or not

+4

I can clearly understand that you want your reduction to be done under your insurance and you can certainly visit surgeons who can write letters to your insurance seeking preauthorization of coverage. But please also know that these are the only breasts you will ever have and many of the very best plastic surgeons no longer work with any insurance as the reimbursement for a breast reduction to the doctor can be as low as a few hundred dollars depending on the insurance. This doesn't even cover the doctor's cost of doing the surgery. So you might want to find the very best surgeon even if they don't take insurance and have them discuss this with you. Look at lots of photos and go to the best doctor regardless of insurance.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 51 reviews

Breast Reduction Insuracnce Requirements

+1
Each insurance company has different guidelines. Moreover, insurance requirements are different depending on state and insurance plan. The process to receive insurance reimbursement for the breast reduction procedure can be quite frustrating.

There are a series of questions that must be answered prior to beginning the insurance process.
1. Have you experienced persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:
Pain in upper back
Pain in neck
Pain in shoulders
Headaches
Painful kyphosis documented by X-rays
Pain / discomfort / ulceration from bra straps cutting into shoulders;
2. Have you had a mammogram within the last year?
3. Have you tried any of the following therapies for 3 months or more?
Supportive devices (e.g., proper bra support, wide bra straps)
Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
Physical therapy / exercises / posturing maneuvers

4. Have you seen a physician for the symptoms you have experienced? When?

Your physician must also be able to document symptoms such as back and neck pain, headaches, also needs to ensure that the estimated reduction is consistent with the insurance company’s requirements for your BMI.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 18 reviews

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Breast Reduction Insurance Criteria

+1
 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 51 reviews

Insurance Coverage & Breast Reduction Surgery

+1

         Breast reduction surgery is often covered by insurance carriers, but breast lift is never covered by these companies. Some insurance companies actually exclude breast reduction as a contract exclusion. When insurance carriers cover breast reduction, they may have specific criteria that must be met. For instance, most insurance carriers require documentation of symptoms. Examples would include back pain, shoulder pain, breast pain and headaches to name a few. They may also require documentation of attempted non surgical management of symptoms. Examples might include physical therapy, support devices and anti-inflammatory drugs. Some insurance carriers require a minimal amount of breast tissue removal from each breast. This is often based on calculations, which utilize the patient’s weight and height.

 

         The process starts with a consultation. At that time, pictures are taken and a prior authorization letter is sent for approval. It typically takes about six weeks to obtain a response. If your insurance carrier’s criteria are met, you are ready to schedule surgery. Blue cross blue shields criteria varies from state to state, but in most states, it has a high approval rate. 

Richard J. Bruneteau, MD
Omaha Plastic Surgeon
5.0 out of 5 stars 89 reviews

Breast reduction and lift

+1
You will likely benefit greatly from a lift and reduction.  The insurance portion only applies to the reduction, but usually a lift is an important part of the procedure to obtain the best looking results.

David Stoker, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 19 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 128 reviews

Insurance coverage

+1

Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.

Sugene Kim, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 40 reviews

Insurance and breast reduction

+1

Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier.  Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front.  Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days.  The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 16 reviews

Breast reduction insurance coverage

+1
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. Make sure you're saying a well-trained/experienced board-certified plastic surgeon. Good luck!

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 793 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.