Likelihood of Insurance Coverage for Breast Reduction?

I am 20 years old, about 5'8'' and weigh roughly 135 lbs. I am a size 34DDD and am really interested in getting a reduction. If I document any pain/discomfort, anything I seek for the pain such as a chiropractor or acupuncturist, etc., what is the likelihood of my insurance covering the surgery?

Doctor Answers (8)

Likelihood of Insurance Covering Breast Reduction Surgery

+2

In my experience, usually a woman with DD or larger will qualify for insurance coverage, if it is a covered procedure under their policy. Most insurance companies require removal of 500 grams or more per breast. All documentation helps in getting approval, including good support bras you have tried, physical therapy and even pain medication. See a Board Certified Plastic Surgeon who specializes in breast reduction surgery, and your surgeon should know how to request pre-authorization from your insurance company. Good luck!


San Francisco Plastic Surgeon
4.5 out of 5 stars 35 reviews

Insurance coverage for breast reduction

+1

I am biased on this question because I gave up any third party payment of plastic surgery procedures although I still do breast reductions. I do them because the patient wants them and understands what is involved including the cost and we don't have to go to someone else for permission. 

Breast reduction is an example of an elective procedure that has both functional and cosmetic aspects and can be considered medically necessary but not like a condition such as breast cancer. If you ask an insurance company or the government to pay for your breast reduction procedure you are giving up control over it. They can dictate whether they cover it, how much they cover, who can do it, and when or where you can have it. 

I choose to let the patient decide whether to do the procedure and how much reduction and how much lift. It doesn't matter what we call it and we don't have to ask for permission. What matters is what's going to be done and what result that should give with what tradeoffs. This doesn't solve the problem of the woman who needs a serious breast reduction and can't afford to pay for it, but this is one way to approach the issue of whether you can have a breast reduction procedure done. 

Scott L. Replogle, MD
Denver Plastic Surgeon
4.0 out of 5 stars 1 review

Breast Reduction and Insurance

+1

Your chances are very likely.  Most insurance companies look for a documented history of back, neck or shoulder pain and some prior treatment which has failed.  They look at your height and weight and plug this into a formula.  It sounds like you would easily qualify.  Check it out and stop suffering.  Your surgeon should get a detailed medical history because some health-care providers demand a history of treatment for back pain to authorize coverage. I measure the breasts and often take photographs to be mailed with the insurance letter. If I don’t comply with the rules, the insurance provider—who holds all the cards—may not authorize paying for the procedure. All the very best, "Dr. Joe"

Joe Gryskiewicz, MD, FACS
Minneapolis Plastic Surgeon
5.0 out of 5 stars 65 reviews

You might also like...

Breast reduction insurance approval

+1

In order to determine insurance coverage for a breast reduction you would need to be evaluated by a plastic surgeon.   Taking into account your height and weight as well as your breast size in addition to the symptoms you describe you will likely qualify for a breast reduction.   It is possible for you to call your insurance company and ask a claims manager what is the method that is used to approve a breast reduction.  Much of this information is available on line if you know the details of your plan.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 10 reviews

Insurance coverge for breast reduction

+1

Many insurance companies will cover large breast reductions but you should really ask your insurance compnay what theor criteria are.  Insurance companies are all different.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

Insurance not likely to cover breast reduction

+1

Normally, a triple D breast would not qualify for an insurance-covered breast reduction surgery. It all depends on documentation and your insurance carrier. Good luck.

Donna Rich, MD
Houston Plastic Surgeon
4.5 out of 5 stars 17 reviews

Insurance Coverage For Reduction Varies

+1

There is no uniform set of criteria for insurance coverage for breast reductions which varies a lot from company to company and also from state to state.  Some policies even have outright exclusions for reductions regardless of symptoms.  In most cases your reduction would be covered if smptoms are well documented and if a sufficient amount of tissue is removed.

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Breast Reduction and Insurance Coverage?

+1

Thank you for your question. Based on your description you may be an excellent candidate for breast reduction surgery; it is one of the most patient pleasing operations we perform.

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 saying a well-trained/experienced board-certified plastic surgeon.  

Prepare to be persistent.

Best wishes.

 

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 791 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.