I have been to two plastic surgeons in the past who agree that I need a breast reduction but my insurance at the time would not cover it. I have deep groves in my shoulders, a pinched nerve in my neck and severe back pain from carring such large breasts. I have a medium frame. I have dieted over the years but do not seem to lose my breast size. Am I a canidate for breast reduction and would my insurance cover the operation?
I Am 5'5" Weighing 165 and Have a Size 36I Breasts. Would BCBS Cover a Breast Reduction for Me?
Doctor Answers 6
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.
Insurance coverage for breast reduction
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.
Criteria for Reduction
Insurance companies cover breast reductions based on 2 criteria. First, you must have symptoms relating to the large breasts such as neck, back or shoulder pain or rashes. You have met that criteria since you have back pain. Second, the amount removed has to meet their requirements. From your height and weight, they calculate your body surface area and use a table that predicts the amount to be removed. At 5'5 and 165 lbs, your body surface area is 1.84 meters squared. If your insurance was Aetna, they would require 705 grams. At size 36 that would correspond to 3 1/2 cup size reduction, which would put you in an approximate size DD.
Gary Horndeski, M.D.
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Insurance and breast reduction
Unfortunately, insurance companies are getting notoriously more difficult to deal with and getting approval for breast reduction surgery. You may have to pay out of pocket to have it done. Good luck.
The only way to determine whether your insurance would cover that is to talk to your primary doctor and they would have to do an authorization for the procedure.
Breast Reduction and Insurance Coverage?
Thank you for the question.
Based on your description you may be a good candidate for breast reduction surgery.
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.
As you know, you may need to be persistent when dealing with health insurance companies. Keep in mind that breast reduction surgery is one of the most patient pleasing operations performed.
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.