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Will Insurance Approve my Breast Reduction? Am I At A Good Weight?

i heard that insurance companies base their approval on height and weight and BMI.. Im about 5'3 and i wiegh anywhere between 180-185. My bra size is 44DDD or 40F. either or, Im not quite sure what my exact size is.. If i were a patient of yours. Would you say that i would need to loose a few pounds before getting approved for surgery or am i a good enough candidate for a breast reduction?

Doctor Answers (5)

Lose Weight Prior to Breast Reduction Surgery

+2

Each insurance is different with what they "authorize" but when you visit a surgeon, they can take photos and document your back pain and write a letter asking for authorization to perform surgery.  I suggest to my patients to bring in any documentation from other doctors, chiropractors, etc that can document what you are experiencing due to the large breasts.  I always send photos and a letter to the insurance company to get authorization.  If you were planning on losing weight, it is best to do it before surgery because the breast size will change with weight loss and so you don't want to do surgery first and then lose weight.   I hope they help you - breast reduction patients are usually THE HAPPIEST patients around.


San Diego Plastic Surgeon
5.0 out of 5 stars 703 reviews

Insurance

+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 115 reviews

Your insurance should cover your breast reduction.

+1

Insurance Coverage for Breast Reduction
Article 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

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Weight Loss and Reduction Surgery

+1

It is difficult to predict whether your ins company will approve your surgery.  If you lose a massive amount of weight such as 60 pounds or more, your breasts will get smaller and your health will improve and you become a better candidate for everything.  It would be a good commitment to make.  But many patients are ok with their larger size.  I would encourage you to consider some options for weight loss prior to having reduction surgery but most likely would perform the surgery on you if you understood the increased risks for wound healing problems.

Steven Holzman, MD
Austin Plastic Surgeon
5.0 out of 5 stars 1 review

Criteria to meet for insurance to approve a breast reduction

+1

Dear Ms Perry,

It is impossible to predict what your insurance might decide since all insurance co. are different in their criteria for breast reduction approval. My advise would be to gather as much evidence/documentation of your symptoms by different doctors. These could include chiropractors, orthopedic surgeons, primary physician, spine specialist, pain specialists. The more proof you have that you are suffering by having such large breasts will help in the approval process. Your PS will take pictures and will write a letter to your insurance carrier (based on your symptoms) and recommendations by other physicians for approval. Unfortunately, despite all the evidence we submit to get you approved, insurance companies will still refuse to pay. If this is your case, you might consider taking on the burden yourself. Many of my patients have done just that and I'm told it's the best thing they ever did for themselves! Best of luck, Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 123 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.