What Documentation Do I Need to Have my Breast Reduction Covered by Insurance?

In summary - 5'0 tall, 170 pounds (BMI of 33.3 qualifying you as Obese) with bra size 38 DDD with neck and back pain and under the breast rash.

A private insurance is a contract between you and an insurance company to partially pay (after co-pays and deductibles) for CERTAIN SPECIFIC medical conditions. Large symptomatic breasts may or may not be part of your particular policy, or in their parlance not a covered benefit. If this is the case, it would not make a difference if you were 100 pounds and had 40FFF breasts with pain of all muscles and every other indication in the book - the insurer would NOT be bound to pay for a non-agreed / (pre)paid for benefit.

The first step is to read your policy and see if you do or do not have "Breast Reduction benefits" or similar verbiage. If you do not, you might as well stop here. If you are covered for such issues, get the insurance policy's most up to date list of "providers", or Plastic surgeons who work with your policy. Contrast this list with a listing of members of The American Society of Plastic Surgeons in your area and study their websites. Then visit 2-3 of these surgeons and see what each proposes.

Every insurance company has its own set of requirements for allowing Breast Reduction. Your chosen surgeon would be best to guide you on what your particular insurer wants to see before approving your surgery.

Good Luck

Hi SD59980.  Sorry to hear about your troubles.  In order to have your insurance company cover breast reduction surgery, you need to build a case and enlist a PS to write a preauthorization letter for you, attaching photos, which will clearly illustrate how you are inconvenienced by the weight and size of your breasts.  I would suggest that supportive letters from your Chiropractor, Primary Care Physician, Dermatologist, Orthopedic Surgeon, etc. would be very supportive as they validate your functional complaints of musculoskeletal discomfort, heat rashes, limitation of activities.  It is also up to you to provide a history: a) the volume of your breasts do not significantly reduce when you loose weight; b) there are other large busted women in your family; c) your mammograms document "dense breast tissue".  Finally, review your insurance company's specific requirements for breast reduction, as they may specify that your BMI (body mass index) has to be within a certain range.  They may also specify how many grams/side should be removed, as they are understandably unwilling to pay for a procedure, which they deem "cosmetic".  Regrettably, as the criteria become more stringent, less cases will be covered, as is the case in the U.K. where breast reduction isn't a covered benefit.  Good luck.