Will Insurance Cover Breast Reduction for D Cup Breasts?

I'm 5'9" with size 32D breasts. I am very athletic and small framed. I would love to get rid of back, neck, and shoulder pain as well as rashes, through a reduction to a small 32B. Am I a good candidate for the procedure?

What advice, if any, do you have for me? Thank you so much for any input!

Doctor Answers (18)

Breast Reduction Coverage

+2

Whether or not an insurance company will cover a breast reduction is always difficult to answer, especially without an examination. The criteria vary a good deal among insurance companies. If your insurance co. uses the usual table to determine coverage, there is at least a chance that they will provide coverage. The only way to know for sure is to have a consultation with a Board-certified plastic surgeon and have him/her communicate with the ins. co. Good Luck!


Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Breast reduction insurance

+1
Depending on your situation, insurance may be able to subsidize the cost of breast reduction. Some breast reduction coverage requirements where I practice in Ontario include your current cup size, the amount of breast tissue removed during surgery, unsuccessful experiences with alternative treatments and medications, as well as recommendations for breast reduction from other specialists, such as chiropractors and neurosurgeons.

Please see an experienced board certified plastic surgeon to find out whether you are a suitable candidate for breast reduction first. Best of luck.


Jerome Edelstein, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 63 reviews

Will insurance cover breast reduction for D cup breasts?

+1
Hello! Thank you for your question.  It is a safe procedure, in which your plastic surgeon will reduce the amount of breast tissue, reshape your breasts, raise the nipple-areolar complex to its appropriate position (possibly making the size smaller, if needed), and ultimately ameliorate the possible complaints that you do have for the reason that you are having this procedure (e.g., neck/back pain, migraines, rashes/infections, shoulder grooving, etc).  Your complaints and physical findings will be important for the authorization

It would be in your best interest to have a mammogram prior to the procedure for screening prior to this procedure, as the architecture imaging of your breast will slightly change afterwards. Well known data exists that having a breast reduction will in fact lower your chance for developing breast cancer, simply because the amount of tissue will be less.

Consult with a board-certified plastic surgeon who will discuss the procedure with you, examine, and assist you in determining if this is the right procedure for you.  Voice your complaints - your insurance will likely require a detailed description of your history and complaints as well as photo and an estimate of how much tissue will be removed.  You should give a description of the therapies that you have done to ameliorate your complaints thus far.  Any other notes from other physicians is helpful.  It would also behoove you to discuss your issues yourself with your insurance carrier.  Hope that this helps!  Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

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Insurance Coverage and Breast Reduction Surgery

+1

         Your symptoms suggest that you would benefit from breast reduction surgery. This procedure has the potential to improve quality of life and has long term health benefits as well.

 

         Most patients with breast enlargement complain of difficulty with back pain, shoulder pain, neck pain, rashes and pain within the breasts themselves. They often have decreased exercise tolerance and as a result gain weight elsewhere. They have difficulty finding clothing that fits properly and they feel that people stare at them. This adversely impacts their self image, self esteem and self confidence.

 

         Correction of breast hypertrophy is a life changing experience. Symptoms improve, clothing fits properly, exercise tolerance improves, patients lose weight elsewhere and self esteem improves following this procedure.

 

         Each insurance company has its own criteria for coverage of breast reduction. In some cases, it may not be covered, in other words it may be a contract exclusion.

 

         In most cases approval of the procedure is dependent upon several variables. Most companies require documentation of symptoms and physical findings, they require a minimal amount of breast tissue removal, and they require failure of conservative management.

 

         If you’re considering breast reduction surgery, consultation with a board certified plastic surgeon is appropriate. Your surgeon will be able to evaluate your situation and write a prior authorization letter to your insurance carrier. 

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

Will Insurance Cover Breast Reduction For D Cup Breasts

+1

Yes, Insurance will cover a breast reduction procedure no matter the patients age if the following criteria are met.

  1. Amount of Tissue to be removed relative to height and weight (most patients go from a D or DD cup to a C cup)
  2. History of symptoms caused by condition:
    1. back problems 2.neck strain 3. bra strap irritation 4. rashes beneath breast
  3. History of trying to improve symptoms with conservative methods:
    1. Physical therapy, oral medication, massage etc.
  4. A letter is then sent for prior authorization by your physician.

Would suggest that you consult with a board certified plastic surgeon and he will be able to give you direction. Also, a link is provided below with more information. Good Luck

Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
3.5 out of 5 stars 4 reviews

Insurance coverage for D cups?

+1

Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier.  Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front.  Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days.  The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.

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Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 15 reviews

Breast Reduction and Insurance Coverage?

+1
Thank you for the question.
Based on your description, you may be an excellent candidate for the breast reduction procedure; it is one of the most patient pleasing operations we perform.
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.
Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.
Good luck!

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 751 reviews

Insurance coverage for breast lift or breast reduction.

+1

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

Breast Reduction and Insurance coverage

+1

Although insurance should give you the benefits you deserve, the results that you may need are best served with a plastic surgeon who performs the surgery commonly, than by a insurance network physicians. Many patients have tried to get their procedure covered but are met with fairly unintelligent blocking mechanisms like weight criteria and gram removal. Most of these delineations don't really help the individual who is trying to get covered and so you will be best inclined to chose a physician first and try to get approval. The process is cumbersome and may still be denied in the end.

The investment for your aesthetic result would be best served by doing this as a cosmetic procedure for yourself leaving the uncaring insurance companies out. Best of Luck

Dr. Zahir

Khalique S. Zahir, MD
Mclean Plastic Surgeon

Insurance coverage and breast reduction

+1

While you may be an excellent candidate for breast reduction, each insurance company has different criterias for approval. You should check with your insurance company. Many want documented histories of the symptoms you describe with treatment that has not alleviated the symptoms with conservative management.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 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.