Breast Reduction: Q&A

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Breast Reduction Size for Insurance to Cover Surgery?

I would like to have a breast reduction. I'm currently a 40DDD. In order for insurance to cover the procedure, what size would I need to go down to?

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23 Doctor Answers | Asked by cole64 in alabama

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Breast reduction and insurance

Dear Cole Altho you may be a 40DDD you don't tell us your height and weight. Many of the insurance companies will look at this as a factor in determining the body surface area and then deciding or setting a scale on what needs to be removed for the procedure to be covered. You may be 5'1" and 100 pounds and need only 350gms per side to be covered while someone 5'8" 210 pounds may need 1000gms per side for the surgery to be covered. Every insurance company is different in their... more

Breast Reduction and Insurance Coverage

One of the great mysteries in medicine is "will my insurance company pay for my breast reduction?" Of course there's no reason that a company that is being paid premiums should hide this information. But they do. So here's what you will need to do. First, your insurance company must provide you with the weight needed to be removed from each breast. They all have their own numbers-anywhere from 500g per side to 875g. And your surgeon MUST remove no less than this. Now the... more

Breast Reduction

It is no longer determined by the 500 gram rule. It all depends on your height and weight which is plugged into a equation which gives BSA (body surface area). This gives a number which determines how much breast tissue is required to be removed for insurance to cover it. It depends now on your height and weight. The heavier your are, the more breast tissue they want removed in order for the surgery to be covered. What will happen at your doctors office is that photos will be taken... more

Amount of Tissue to be Covered for Breast Reduction Surgery

The vast majority of insurance carriers require prior authorization for breast reduction surgery. Multiple criteria must be met before authorization can be granted. One of the more important insurance criteria for approval is the anticipated amount of breast tissue to be removed. This number varies from insurance carrier to insurance carrier. Many insurance companies use weight and height calculations to determine how much tissue should be removed from each breast. In... more

Breast reduction size for insurance to cover surgery.

Thanks for your question. Insurance companies look at the overall size of the patient not the patients breasts when determining how much tissue must be removed. In other words, if we use an example of patient 1 and patient 2 who both have 40 DDD breasts. And say patient 1 weighs 100lbs and is 5 feet tall while patient 2 weighs 185lbs and is 5'8''. Patient 1 would need far less tissue removed to satisfy insurance requirements than patient 2. Insurance goes by... more

Breast Reduction Size for Insurance Coverage

Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria. 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... more

Breast Reduction - Insurance Coverage

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... more

Insurance coverage for breast reduction

The criteria for insurace coverage for breast reduction vary widely from company to company and plan to plan . ALL insurance companies require 1/ The patient has medical problems related to her breast size (back, neck, shoulder pain; rashes under the breasts; etc.); 2/ A minimum amount of breast tissue must be removed by the surgeon; 3/. Active insurance coverage. The exact symptoms required will vary by company, as will the necessary... more

Breast Reduction Surgery

Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance. Insurance companies have become more stringent in their approvals for surgery.. I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well). Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the... more

How much tissue to remove during a breast reduction

Patients today have many great options to effectively reduce and contour their breasts. In our practice, we work closely with patients to understand what their goals are and how much breast tissue is necessary to alleviate any pain symptoms that they may have and to obtain the look that they are looking for. Before the surgery, we can sometimes give an estimate as to how much tissue will be removed. However, there is no exact way to determine how much breast tissue will be resected. Be... more

You probably will get Insurance coverage for breast reduction.

Hi! Every woman is different and every insurance policy is different. But you probably need to have at least 500 grams of breast tissue removed from each breast, and this often meets insurance requirements.

Breast reduction and insurance

In order for breast reductions to be covered by insurance, several criteria need to be met. Patients must have a documented history of symptoms such as neck/back pain and show some type of treatment for this-pain medication, physical therapy, accupunctur, etc. Also, the insurance companies will require photographs of the patient and a medical letter of necessity written by the plastic surgeon. The insurance companies also need to see about 500 gms of tissue removed from each breast in... more

Breast reduction and insurance coverage

Breast reduction has one of the most satisfied patient populations of any plastic surgery procedure. Whether or not insurance will cover the procedure really depends on your specific plan. Each insurance company will have many different plans and sometimes an employer may set their own rules for coverage. Over the last 5yrs it hase become increasingly difficult to get approval for breast reduction. The criteria that each patient has to meet and the amount that has to be removed have... more

Breast reduction size is only one factor in determining insurance coverage

It has become more apparent with the recent health care debate that insurance is a regional issue and coverage will differ widely state to state, and locally plan to plan. People are also discovering that a company such as Blue Cross will issue dozens of differing plans with differing levels of coverage. Generally most feel that because of the fact that they have insurance they must be covered for what their doctor feels is necessary care. Unfortunately what is necessary is increasingly... more

Breast reduction size for insurance coverage

First, you need to look at your insurance book to see if your PARTICULAR policy even pays for breast reduction surgery. Each insurer sells different VERSIONS of its policies and just because you have let's say CIGNA does NOT mean that YOUR policy is the same as your neighbor's. They are not. IF your policy does not pay for it, you will not be able to change their mind by writing letters. The law is on their side and frankly you are wasting your time. If your policy does pay for this... more

Insurance for breast reduction

Most insurance companies would cover the reduction of extremely larger breasts in symptomatic patients. If the patient has a history of bra strap grooving, neck and back pain that is documented it has a good chance of getting covered provided that you fall within macromastia criteria consistent with your height and weight.

Steven Wallach, MD

12 reviews

Manhattan Plastic Surgeon

Insurance for breast reduction

Insurance for breast reduction surgery is highly variable. Often there are a number of conditions that must exist before your insurance would consider it medically necessary. This includes presence of infection, rashes, ulcers, back pain, shoulder grooving. However, some are qualified by requiring you to have enough pain to require analgesics, or to see an orthopedic surgeon or therapist or chiropractor for a minimum amount of time. Some require you to be within a certain percentage of your... more

Robin T.W. Yuan, MD

4 reviews

Beverly Hills Plastic Surgeon

Breast Reduction Size

Every insurance company has their own criteria. You should check with your company. Your doctor should be able to show you what the reduction amount looks like by showing you that size of breast implant. It gives you an idea of what will be removed and what you will have left in place.

Insurance will pay for breast reduction

Most insurance companies require around 500gms per side for approval. That is not an absolute amount but I have had no trouble getting the go ahead from providers when this estimate is made. Judging from your remarks, you might be as large as a "D" cup if only this amount were removed. Most women in my practice want to end up as a "C" cup, but not always. In your case, an estimate of at least 500 gms per side would be placed on the insurance pre-approval forms along with... more

Breast Reduction Insurance Coverage

Most insurance companies compare your symtoms with the estimated weight of tissue to be removed in conjunction with your body surface area. The threshold varies and some policies have an exclusion for reductions. I would estimate that you would need to go to a D or C cup to meet the requirements. I agree that a plastic surgeon can assist with the process.

Insurance coverage for breast reduction is inconsistent

This is one of the most inconsistent issues in our health care system. Your insurance company has certain"guidelines" to allow coverage for different procedures. You are required to present lengthy documentation to prove that this procedure is necessary. Once approved, the insurance company issues a pre-Authorization letter to your doctor. The twist here is that pre-authorization is not a guarantee of coverage and payment! Which means that you could be left with the bill to pay! It... more

Your doctor can help you after examination preaproval

I would refer you to a board certified plastic surgeon. He or she will examine you and then submit a preaproval to your insurance company. The coverage and criteria for the aproval is not standard.

Kamran Khoobehi, MD

28 reviews

New Orleans Plastic Surgeon

There are no hard and fast guidelines for breast reduction coverage or insurance elegibility

It's not necessarily the size and different carriers use different methods to determine elegibility for coverage. BCBS commonly uses the Schnur scale based on BMI and estimated weight of resected tissues. However, they are not always consistent and it has been my experience that they do not always follow these guidelines. Your best bet is to go for a consultation and have a letter submitted to determine your level of benefit coverage.