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?
Breast Reduction Size for Insurance to Cover Surgery?
Doctor Answers (25)
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 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.
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.
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Breast Reduction Candidate seeking insurance coverage
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
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.
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 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.
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 body surface area which is a factor or weight and height, not breast size. Hope this helps.
Breast Reduction Size for Insurance Coverage
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
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 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,
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 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.
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 large breasts. Supporting documentation is usually very helpful.
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.