Ask a doctor

How to Convince Insurance to Cover Breast Reduction?

I am 20 years old and I have 38DD breasts. I would love to get a breast reduction because as long as I can remember I have had back, neck and knee problems. I have horrible posture and running and  exercising is difficult because my breasts get in the way. I can't afford it myself so I was wondering how to prove to your insurance that my large breasts are causing my pain? Thank you for your time.

Doctor Answers (15)

Insurance coverage for breast reduction

+2
My staff is expert at dealing with insurance carriers and it is not a matter of being convincing. Each insurer has its own set of criteria, which change regularly and what is essential is to know and understand the rules and then be willing to jump through the hoops. They are continuously making it more challenging. It is also important that your plastic surgeon provide all supporting information required and to be prepared to appeal on your behalf, based on the peer reviewed literature. I am personally disturbed that insurers spend millions of dollars on advertising about preventive care and then try to deny these cases. After breast reduction, a patient's ability to exercise is greatly improved and this can only contribute positively to health and wellbeing.


New York Plastic Surgeon
5.0 out of 5 stars 8 reviews

Some insurance companies will cover Breast Reduction procedures

+1

Some, not all, health insurance companies will cover the cost of a breast reduction procedure.  To qualify you will have to meet all the requirements set forth in their policy, which vary widely from company to company.

The insurance companies will need to have a pre authorization letter sent to them by the surgeon which describe the reasons for requesting the procedure.  A minimum amount of tissue will need to be removed at the time of surgery based on your body mass index, a photograph documented the deformity will be needed, symptoms relating to the breast weight will need to be documented.  Some carriers will even require 6-9 months of "conservative therapy" for the neck, shoulder and back pain with PT/OT therapy, anti-inflammatory medication usage and supportive bras (who ever heard of a non supportive bra!).  Basically, they are looking for any excuse to not cover the procedure, it may take multiple letters and appeals to determine coverage.

Good Luck!

David Finkle, MD
Omaha Plastic Surgeon
5.0 out of 5 stars 45 reviews

Insurance coverage for breast reduction

+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 113 reviews

You might also like...

Insurance

+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
Houston Plastic Surgeon
4.5 out of 5 stars 35 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 13 reviews

Criteria for Insurance Approval of Breast Reduction

+1

Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc. Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria.
The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.
Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :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 though insurance criteria are becoming more and more restrictive.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 38 reviews

Insurance Coverage for Breast Reduction Surgery

+1

Insurance coverage for breast reduction surgery varies from company to company and requires that you meet certain criteria.

These include documentation of neck and back pain, documentation of physical therapy for the neck and back pain, an insurance-specified anticipated minimum  amount of breast tissue removal,  and photographs.

This information will need to be submitted to the insurance company by the plastic surgeon's office for authorization to cover the breast reduction surgery.

Fredrick A. Valauri, MD
New York Plastic Surgeon

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 680 reviews

Breast Reduction and Insurance Coverage

+1

Dear kdaniels39,

Each insurance company is different and, not surprisingly, it is become harder and harder to get insurance companies to pay for this procedure.  In general, though, they will cover the procedure if you can show that removing the indicated amount of tissue (more on that below) will be likely to alleviate certain specific symptoms.

First, then, you have to have those symptoms.  Typically they would include neck, back and shoulder pain, bra strap grooving and/or intertrigo (rashes underneath the breasts).  The inability to exercise or to sleep comfortably can be additional symptoms.

Then, you have to have "enough" tissue removed.  Understandably, if only a small amount of tissue is removed the insurance company is more likely to consider it a cosmetic procedure (called in that case a "breast lift" rather than a breast reduction).  It used to be that a breast reduction would be more likely to be "covered" as long as 500 grams - a little over a pound - was removed from each breast.  Now, though, it is typically more complicated.  In general, you have to remove a certain amount of breast tissue relative to your body mass index.  Here's a site that can help you determine your body mass index nhlbisupport.com/bmi/.  Even then, though, you will have to find out from your insurance company how much tissue has to removed in order to qualify.  Companies don't normally publicize their criteria widely, but they may and, in the meantime, this something that your plastic surgeon may be able to help you with.

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 145 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

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.