Would my Insurance Possibly Cover Reduction? (photo)

I'm 5'7" and 145 lbs. I wear a 36DDD and have been struggling with back and shoulder pain as well as struggling to find bras and clothes that fit me properly. I am 18 years old and have been dealing with this since about the age of 14. I now have a 4 month old daughter who I nursed for 2 months, so my breasts have grown a little but are much, much heavier. Is reduction a good idea?would my insurance possibly help cover the cost of surgery? Also, would it be reasonable reduce to a size c?

Doctor Answers (14)

Insurance for breast reduction

+3

Hi HannahNiccole, 

thanks for the post. this is a great question with a difficult answer. Yes, you are an excellent candidate for a breast reduction. A medium to full c is not unreasonable.

Insurance coverage depends on your insurance carrier and type of plan you have. As you will soon discover, insurance companies are VERY difficult to deal with and try hard NOT to cover this. they consider this a cosmetic procedure. 

You should: 

1. call your insurance company. Look at your policy. determine what if any coverage you have. make note of the deductible / copay issues. See if you have any out of network benefits. If not, like an HMO, you must use the doctors who participate with your plan. 

2. consult with your Primary care MD. they will need to write a supporting letter for your procedure

3. get a consult with an orthopedic surgeon or back doctor who also supports the medical necessity of this

4. Have a consult with a board certified plastic surgeon. Make sure your size goals and the PS size goals are on the same page. Have realistic expectations. insurance companies often have size requirements for coverage. Make sure your PS thinks he / she can remove that much safely and leave you with a nice shape and volume. 

 

My only other comment is that you are only 18 years old. there is a chance you will have more children. If so, your breasts may grow again and need to have this procedure repeated. It's a small risk, but you need to be aware of this. 

It takes about 1-2 weeks of recovery before you can return to normal activities. a month before you can exercise again. 

best wishes. 

 


Rockville Plastic Surgeon
5.0 out of 5 stars 8 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

Most likely yes

+1

Most likely your insurance should cover this, unless you have very bad insurance.   Your breasts look quite large and pendulous and probably cause some medical problems.  It helps to tell them about your back, and neck problems if you have them.

Best Regards,

Dr. Lane Smith

 

Lane Smith, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 27 reviews

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Breast Reduction and Insurance Coverage?

+1

 Thank you for the question and picture.


Based on your description and picture, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations we perform. 
You will need to check with your insurance company directly to see whether your policy covers this operation. They will also be able to tell you whether you will have any direct responsibility/expenses if you choose to undergo this procedure.


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.


 It will be very important for you to communicate your goals, concerns, and questions with your plastic surgeon. 
In my practice, I ask patients to collect "goal  pictures”  of breasts which they like, breasts that are too big, and breasts that are too small as well.  I find that the use of pictures is more helpful than the words such as "C cup", “natural” or "proportionate” etc., which can mean different things to different people.

Many of my patients choose to have enough breast tissue removed to help alleviate symptoms while retaining enough breast tissue to remain proportionate to the remainder of  bare torso. Again, preoperative communication will be critical.
 

I hope this helps.

  

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
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Therapeutic Breast Reduction

+1

Breast Reduction is many times covered by insurance  if certain criteria exist ,such as shoulder and back pain and irritation under the breast.

This procedure is functional in relieving discomfort but also helps with increased confidence and self-esteem. It is true as you know , that your breasts can change after pregnancy, but if your breasts interfere with your quality of life, then doing this procedure at a younger age can be appropriate

Algird R. Mameniskis, MD
Chicago Plastic Surgeon
4.5 out of 5 stars 11 reviews

Breast Reduction Covered by Insurance?

+1

Many women wait until they are finished having children before having  breast reduction surgery as pregnancy could result in needing additional surgery. However many women are very uncomfortable and choose to go ahead. You need to have stopped lactating for 3 to 6 months before surgery and understand that if you are planning to have more children that your ability to breast feed may be reduced somewhat or altogether.

With that being said you are a good candidate and it will depend on your insurance policy if your surgery would be covered. See a Board Certified Plastic Surgeon who specializes in breast reduction surgery and he/she will be able to help you get pre-authorization. If you should get denied, ask the surgeon to appeal your case, I have gotten coverage for several patients this way. Good luck!

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon
4.5 out of 5 stars 30 reviews

Insurance and Breast Reduction

+1

If you are having physician documented neck and back pain and have tried non surgical treatments (physical therapy, Chiropractic care,etc) then your insurance should cover it.  Your plastic surgeon's office should help you determine if you qualify.

Good Luck

Dr. ES

Earl Stephenson, Jr., MD, DDS
Atlanta Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance coverage for breast reduction

+1
You appear to be an excellent candidate for reduction in terms of breast size and BMI. See a board certified plastic surgeon in consultation who can review your insurance criteria and deal with the pre certification process.

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

Would my Insurance Possibly Cover Reduction?

+1

Every insurance company is different, however from your photos, it appears that you should be covered.  Best to call your insurance and see what your coverage benefits are.

Amy T. Bandy, DO, FACS
Newport Beach Plastic Surgeon
5.0 out of 5 stars 86 reviews

Breast reduction

+1

It is very possible that your insurance may cover your breast reduction.  Each insurance company requires different things and it is best to find that out in advance. Good luck.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 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.