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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?

Doctor Answers (23)

Breast reduction and insurance

+2

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 requirements and there may be 100 different policies within each insurance company with as many different requirements. I would suggest having your doctor write a letter of preauthorization so you can determine if there are any out of pocket expenses you may incur.

Good Luck!


Boca Raton Plastic Surgeon
4.5 out of 5 stars 3 reviews

Breast Reduction and Insurance Coverage

+2

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 stuff they won't tell you. Since I review cases for insurance companies I'll tell you exactly what you need. 1. You must see your primary care doctor on AT LEAST 3 separate visits solely for the purpose of neck, shoulder and back pain, shoulder grooving etc related to the breasts. 2. You must document the various bra or bras you have used 3. You must undergo physical therapy for several months 4 Weight loss must be attempted and documented how. 5. The medications you use for the pain/discomfort must be documented 6. You must have a referral letter from your PMD to the plastic surgeon 7. A thorough exam and documentation from the plastic surgery must be included.

All of this must be documented. If the preauthorization letter denies the surgery then this documentation is necessary to plead your case.

Christopher L. Hess, MD
Fairfax Plastic Surgeon
5.0 out of 5 stars 18 reviews

Breast Reduction

+2

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 and your surgeon will submit all this information along with the symptoms you are having to the insurance company, which will them determine if it is medically necessary.

Good luck.

Farbod Esmailian, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 39 reviews

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Amount of Tissue to be Covered for Breast Reduction Surgery

+1

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 most cases, estimating the amount of breast tissue to be removed is relatively straight forward.  In borderline cases it can be very difficult.  Under these circumstances it may be impossible to meet the insurance carrier’s specimen weight criteria and still meet the patient’s aesthetic goals.  In this situation, the patient may have to answer a difficult question before proceeding with surgery regarding which issue is more important to them.
Even when these choices need to be made, the vast majority of patients are extremely happy with the size of their breasts following breast reduction surgery because their primary goal is resolution of their symptoms.  If you’re considering breast reduction surgery, consultation with a board certified plastic surgeon with experience in this area will be helpful.  An appropriate estimate of the amount of breast tissue to be removed should be easily accomplished.

Richard J. Bruneteau, MD
Omaha Plastic Surgeon
5.0 out of 5 stars 78 reviews

Breast reduction size for insurance to cover surgery.

+1

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 body surface area which is a factor or weight and height, not breast size.  Hope this helps.

Shaun Parson, MD
Phoenix Plastic Surgeon
4.5 out of 5 stars 29 reviews

Breast Reduction Size for Insurance Coverage

+1
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 operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. For you that would most likely reduce you to a large C to a large D cup size.. 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. 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 47 reviews

Breast Reduction - Insurance Coverage

+1

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.

It used to be that a 500 gram reduction on each side would be enough to obtain coverage; that is no longer the case and you cannot assume anything with respect to this.

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.

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.

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 151 reviews

Insurance coverage for breast reduction

+1

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 documentation of these symptoms and the required prior attempts at "conservative" treatment.  The required amount of breast tissue removed can vary from a certain fixed amount (usually 400-500 gms) or it can be determined by a sliding scale based on BMI.  Some companies will deny any patient over a certain BMI.

Your medical insurance company is required to provide you with their policy regarding coverage for breast reduction (or any procedure for that matter).  Study the policy, fulfill the requirements, have the Plastic Surgeon of your choice submit a request for coverage for the procedure, and (with a little persistence) you should be able to get your surgery covered.   Good luck, and stick with it.

Robert Stroup, Jr., MD, FACS
Cleveland Plastic Surgeon
5.0 out of 5 stars 6 reviews

Breast Reduction Surgery

+1

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 large breasts. Supporting documentation is usually very helpful.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 757 reviews

How much tissue to remove during a breast reduction

+1

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 sure that you review your insurance policy and how closely with your plastic surgeon about your goals. Remember that these are the breasts that you will live with aunt is more important for you to obtain the results that you are looking for then to satisfy a meaningless number for an insurance company.

Pat Pazmino, MD
Miami Plastic Surgeon
4.5 out of 5 stars 67 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.