How Does Insurance Coverage Cover Breast Reduction Surgery?

I'm 16, 120 lbs, 5'3", with 32DD breasts who wants to go down to a32B. I've found a surgeon, and gotten a consult. The plastic surgeon said that I would have to have more tissue taken out than I have in order for insurance to cover it. I sent in a pre-approval request, made out by my general practitioner, to my insurance company, Blue Cross/Blue Shield of Alabama. Does insurance pay for the surgery before it is done, or do you pay out of pocket and they reimburse you?

Doctor Answers 22

How Does Insurance Coverage Cover Breast Reduction Surgery?

Every insurance plan is different, and I cannot tell you specifically whether you would be covered under your plan or not. Some plans require a certain minimum amount of tissue be removed, usually based on your height and weight. Some plans require a demonstration of failure to more conservative approaches such as physical therapy. Some plans offer no coverage at all. Your surgeon can ask your insurer for a predetermination of medical necessity to find out in your case. This will usually require the submission of a letter describing your history, your complaints , the amount of tissue planned to be removed, and a photograph of your breasts. Good luck!

Columbus Plastic Surgeon
4.5 out of 5 stars 16 reviews

Breast Reduction and Insurance Coverage

Hi Sarah101,

Each insurance company is different and, not surprisingly, it is become harder and harder to get insurance companies to pay for this procedure. In general, though, they will cover the procedure if you can show that removing the indicated amount of tissue (more on that below) will be likely to alleviate certain specific symptoms.

In general, the procedure has to be performed before any payment is made.  Depending on the exact insurance company, the payment will either be made directly to the surgeon or, in some cases, you have to pay the surgeon and then you will be reimbursed, fully or partially, by the insurance company.  These are obviously things that you'll want to check out before you proceed with the surgery.

First, then, you have to have those symptoms. Typically they would include neck, back and shoulder pain, bra strap grooving and/or intertrigo (rashes underneath the breasts). The inability to exercise or to sleep comfortably can be additional symptoms.

Then, you have to have "enough" tissue removed. Understandably, if only a small amount of tissue is removed the insurance company is more likely to consider it a cosmetic procedure (called in that case a "breast lift" rather than a breast reduction). It used to be that a breast reduction would be more likely to be "covered" as long as 500 grams - a little over a pound - was removed from each breast. Now, though, it is typically more complicated. In general, you have to remove a certain amount of breast tissue relative to your body mass index. Here's a site that can help you determine your body mass index Even then, though, you will have to find out from your insurance company how much tissue has to removed in order to qualify. Companies don't normally publicize their criteria widely, but they may and, in the meantime, this something that your plastic surgeon may be able to help you with.

I hope that this helps, and good luck,

Dr. E

Insurance coverage for breast reduction surgery

Insurance coverage for breast reduction varies from state to state. Most carriers require a letter from the plastic surgeon estimating the amount of breast tissue to be removed, so  the letter from your primary care physician will not contain sufficient information to allow them to make a decision.   Your plastic surgeon will need to send a letter to the insurance company, who will them decide if your case fulfils their criteria for coverage.  This needs to be done before the surgery.  If your insurance company covers the surgery, your parents should discuss their  financial obligation with the plastic surgeon, as the insurance MAY cover only a portion of the cost.

Beverly Friedlander, MD
Short Hills Plastic Surgeon
5.0 out of 5 stars 12 reviews

Breast reductions and the Schnur scale

Many insurance companies use the Schnur Table (Google it...) to determine the minimum that a surgeon needs to remove from each breast in order for the insurance company to pay for the procedure. In smaller women like yourself, this is sometimes difficult to leave you with enough breast tissue for a good cosmetic result. Insurance companies do not pay for cosmetic surgery (nor should they...)

Insurance Coverage and Breast Reduction Surgery

Insurance practices differ from practice to practice. You will need to clarify that point with the surgeon that you choose.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 27 reviews

Breast Reduction For Minors and Insurance Authorization

Breast Reduction Under 18 Yrs Old and Insurance Criteria:

First of all you will need approval from your parents as you are under age unless you are an emancipated minor. Secondly, It is best to wait until your breasts have fully grown.

From your description it seems as if you are a good candidate for breast reduction. Unfortunately, each insurance company has their own criteria. 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 through 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

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 76 reviews

How Does Insurance Cover Breast Reduction Surgery?

        From your stature (5'3" , DD cup, and weight of 120lb.). It appears that you would have a very good chance of getting pre-authorization for insurance coverage. Most insurance carriers consider the following before providing coverage.

        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:

          Physical therapy, oral medication, massage etc.

        4. Once these criteria are met and forwarded to your insurance. If they approve then your insurance carrier will cover the cost of the surgery for the fee that they will outline to you prior to the operation.

Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
4.0 out of 5 stars 7 reviews

Breast reduction with insurance

Insurance companies have become more particular back cover and breast reduction these days in fact many insurers have written breast reduction out of coverage all together you would have to find a doctor that accepts your insurance.

Insurance coverage for breast reduction

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

Determining insurance coverage for breast reduction surgery

Insurance coverage is a fickle thing.  The only way to know for sure is to be evaluated by a plastic surgeon.  At this time a pre-approval letter will be sent.  The insurance company reviews the information and magically make a medical decision whether or not they intend to cover the procedure.  It is not always a fair or just decision.  From your description you seem to be a good candidate for the operation and would get symptomatic relief from your large breasts.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 13 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.