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?
How Does Insurance Coverage Cover Breast Reduction Surgery?
Doctor Answers (20)
Breast Reduction Insurance Coverage?
Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.
Based on your description you may be a good candidate for breast reduction surgery; for physical and emotional reasons. 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.
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!
Breast Reduction and Insurance Coverage
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 nhlbisupport.com/bmi/. 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,
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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.
How Does Insurance Cover Breast Reduction Surgery?
- Amount of Tissue to be removed relative to height and weight (most patients go from a D or DD cup to a C cup)
- History of symptoms caused by condition:
- back problems 2.neck strain 3. bra strap irritation 4. rashes beneath breast
- History of trying to improve symptoms with conservative methods:
Physical therapy, oral medication, massage etc.
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.
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.
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.
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.
Generally insurance pays the bills and you pay the balance
Generally the insurance company pays their share and you pay yours. Sometimes you have to pay the co pay up front. It depends on your insurance policy . Your surgeon and her or his staff will assist you with these issues. Good Luck! Dr Grant Stevens
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.