Ask a doctor

Insurance Worry for Breast Reduction. Do You Think I Will Be Approved?

Hi everyone, i am a 20 year old college student. I have a breast reduction scheduled for may 25th. Even though i have not been approved yet , my ps scheduled me because i am in a time crunch since im home from college to work for the summer. I went in on april 2nd for a consult and it has been about 4 1/2 weeks. Im getting more nervous every day that i wont be approved. I have double upmc insurance. I am 5'3 , 175 pounds, athletic and very top heavy. Do u think i will be approved? I am a DDD.

Doctor Answers (6)

Breast Reduction Insurance Issues

+1
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


Orange County Plastic Surgeon
5.0 out of 5 stars 47 reviews

Insurance

+1

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

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 123 reviews

Insurance approval

+1

At 5'3 and 175 lbs, your body surface area is 1.87 meters squared.  If you have Aetna insurance, they would require 740 grams removed.  If you are 32 or 34 then each cup size corresponds to 100 cc's, if you are 36 or 38 then each cup size corresponds to 200 cc's and if you are 40 or 42 then each cup size corresponds to 300 cc's.  Using this information, you can predict the size you would end up, which may or may not be satisfactory.  Also, insurance companies require you to have symptoms such as pain, rashes or infection, which you have not described.  Gaining approval will require letters from your primary care physician, gynecologist or chiropractor describing symptoms of back pain, infections or complications.

Best of Luck,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 126 reviews

You might also like...

Insurance Approval for Breast Reduction?

+1

As much as I would like to be able to provide you with reassurance, only communication with your insurance company will be helpful in doing so. It won't hurt for you to call the insurance company;  hopefully you will be able to make contact with a helpful person who can tell you the status of your “authorization”.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 757 reviews

Breast reduction approval

+1

I think that you have good cause to be a bit nervous. Most insurance companies respond within a few weeks and almost all within a month of the request being issued. I would simply call your insurance company and ask for a status update on your case. You are going to have to endure a few voice prompts, but it will be worth finding out for sure. Even though your surgery is scheduled, I doubt that your surgeon will perform your surgery before there is either an approval from the insurance company or he is holding your check for the out of pocket cost of the procedure. But the worst thing for you would be for you to get bills in the mail from your surgeon, the anestheia team, and the hospital in the case that it wasn't approved.

William T. Stoeckel, MD
Raleigh-Durham Plastic Surgeon
5.0 out of 5 stars 39 reviews

Breast reduction approval

+1
The only party who can tell you whether you'll be approved is the insurance company. In NY, there is a time parameter within which they must approve or deny a case and, even so, they do not adhere to the statutory guidelines. Here, you could likely be denied because of BMI and being overweight unless, for some companies, you had extremely well documented unsuccessful medical management, including physical therapy or chiropractic for 3-6 months, pain medication, orthopedic workup, etc. Best of luck. Check your insurance guidelines on the company's website to see if you have clearly failed to meet its specifications to give yourself a framework within which to understand the insurance process.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 12 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.