I'm 28 and I have Medicaid but I was wondering if a Breast reduction would be covered. I have one breast that measures as an EE and the other as a DDD and it looks very weird in clothing I'm stuffing one side of my bra and I have deep grooves in the shoulders with horrible back pain.
Will Insurance Cover Breast Reduction of EE and DDD Breasts?
Doctor Answers (15)
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.
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.
Breast reduction and medicaid
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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Insurance, medicare, and medicaid usually pay for reductions of this size.
When you go for your initial consultation your surgeon should be able to answer the question with more assuredness.
Will Insurance Cover Breast Reduction of EE and DDD Breasts
Insurance carriers vary on what type of surgeries they will cover. Some insurance companies have a written exclusion for breast reductions and it becomes more difficult each year to have these procedures approved. When an insurance carrier does cover breast reductions there are certain criteria such as symptoms of neck and back pain, grooving of the shoulders and intertriginous rashes. The surgeon must evaluate and determine how much breast tissue will be removed and see if this amount meets the insurance carrier’s inclusion criteria. The amount is usually 500 grams per breast.
Insurance Coverage for Breast Reduction
Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company but from your photos and description I believe that Medicaid will cover this procedure for you. Contact Medicaid 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. 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
Large Breasts, Bra Furrows, and Neck Pain
Based on the information in your question with large breasts, bra furrows and neck pain, breast reduction surgery is very well may be covered by Medicaid depending on the local carrier.
My advice is for you to see a plastic surgeon and be evaluated. Photographs and all of the necessary documentation can then be sent to your insurance company for authorization.
Insurance coverage for reduction of EE breasts
Breast reduction insurance coverage
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 saying a well-trained/experienced board-certified plastic surgeon. Good luck!
Insurance coverage for EE and DDD breasts.
Thank you for including a photo. You do indeed have large breasts that would be appropriate for reduction mammoplasty, and you would likely be extremely happy with the results after properly-performed reduction (which also lifts the nipple position and improves symmetry between breasts!
However, large breasts are often associated with large women, and that is why many, if not most, insurance providers (including Medicare, Medicaid, and state insurers such as MinnCare here in Minnesota) require a certain amount of breast tissue to be removed based on height and weight of the patient ALSO, not just breast size and subjective symptoms.
Thus, if you are 5 foot 2 inches tall and weigh 185 lbs, for example, your surgeon would need to remove a minimum of at least 542 grams per breast (about 1.2 lbs per side). For the breasts depicted in your photographs, this would leave plenty of tissue to give you breasts that are still full and shapely, but more symmetrical and much less heavy! But if you were 5 foot 8 inches tall and weigh 210 lbs, for example, your surgeon would need to remove at least 803 grams per breast (almost 2 lbs per side) in order to qualify for coverage. This would still likely leave you with adequate breast tissue and a nice feminine form based on your photograph, but you can see that slightly smaller (but still large) breasts in a tall, heavy woman might not qualify for coverage without nearly mastectomizing her! Trust me, too small is almost as bad as too big!
Bottom line: you appear to be an appropriate candidate, not only for the surgery, but also for coverage. See an ABPS-certified plastic surgeon who has extensive experience in breast reduction surgery and forge ahead! You will be glad you did! Best wishes!
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.