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How do I get insurance to cover a breast reduction?

I have 22, 5'9", 190 pounds with size 36g breasts. What do I need to do to get premera to cover a reduction? My doctor wants me to lose 40 pounds but being a naturally curvy person this seems like a ridiculous amount to lose

Doctor Answers (3)

How do I get insurance to cover a breast reduction?

+1
Thank you for your question.  Your doctor has your best interest in mind.  He probably has determined that you will lose breast size with weight loss, therefore he has recommended the weight loss, thinking that you may avoid a breast reduction, or at least you will need a smaller operation.  However, insurance companies vary tremendously in their guidelines for authorizing a breast reduction and you have to find out what your insurance's guidelines are.  This is usually done through your experienced board-certified plastic surgeon's office.  Best of luck.


Beverly Hills Plastic Surgeon
5.0 out of 5 stars 12 reviews

How do I get insurance to cover a breast reduction?

+1

Thank you for the question.
Based on your description, you may be an excellent candidate for breast reduction surgery. Your plastic surgeon is correct in that achieving (as close to possible)  your long-term stable weight, will help improve the safety of the operation and the outcome of the procedure as well.  
You will need to check with your insurance company directly to see whether your policy covers this operation. They will also be able to tell you whether you will have any direct responsibility/expenses if you choose to undergo this procedure.
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.  when dealing with health insurance companies, prepare to be persistent. Keep in mind that breast reduction surgery tends to be one of the most patient pleasing operations performed.
 I hope this, and the attached link, helps. 

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 781 reviews

Insurance coverage on reductions is hard

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Thanks for your question. Without an exam it is hard to predict how much breast tissue can be removed. Insurance companies typically want someone with a BMI of less than 30 and resection volume over 500gm. If you have been seen by your primary care physician for several years and this has been documented, then that too will help. Lastly if you can demonstrate attempts improve your pain with physical therapy without success then that is in your favor. Basically you need a track record of exams and therapy, a reasonable weight, and a certain amount of anticipated breast tissue removal. Even these things won't guarantee removal. Less than 20% of the reduction requests we send in get approved. Best of Luck!

M. Scott Haydon, MD
Austin Plastic Surgeon
5.0 out of 5 stars 44 reviews

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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.