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Would I Qualify for Breast Reduction? Would Insurance Pay? (photo)

I am 18 years old, 5'11, 150 lbs, and I wear a 30K bra. I am in almost constant lower back pain, and have 2 bulging disks. I also have to have all of my shirts/dresses tailored for me, as nothing ever remotely fits properly!!! I thought exercising would help, but I walk, run and workout 1-2 hours a day, every day for over 3 years with very little relief. Being almost 6' is hard enough, so I would like at least some sort of normalcy...

Doctor Answers (7)

Insurance coverage for breast reduction

+1

Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.


Houston Plastic Surgeon
4.5 out of 5 stars 38 reviews

Breast reduction

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Although hour breast are ptotic, meaning they are sagging, they don't appear large enough to qualify for a breast reduction. they would more likely benefit for a breast lift, or a mastopexy.  Although you suffer from back pain, it is does not appear that your breasts are contributing significantly to the problem.  You should consult with a board certified plastic surgeon in your area for an evaluation for their professional opinion, since sometimes it is difficult to tell just from photos.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 9 reviews

Your surgery would be considered a cosmetic mastopexy and not a reduction

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You have breast ptosis (droop) without significant volume. This type of procedure you'd use  is most acurately described as a breast lift (mastopexy) and would not be considered a medically necessary breast reduction procedure by insurance carriers.

Robert Oliver Jr., MD
Birmingham Plastic Surgeon

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Bresat reduction

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It is tough to say bassed upon a photo, but from the photo they do  not look that big.  An in person exam may be different thana a photo.  You s houdl check with your insurance company regarding their coverage policies.

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

Insurance Coverage

+1

It depends on your insurance. There are many factors that go into coverage by insurance of a breast reduction. I have created a list of problems or information that insurance companies  will need to see and/or review before approval

1. Insurance companies want to see a large breast size in relation to a patients weight.  Another words if you are 120 lbs and have D cup breasts you are a good candidate. If you are 220 lbs and are only a D cup insurance approval will be less likely. 

2. Insurance companies like to see a reduction potential of at least 500 grams per side, although studies have shown reductions as small as 250 grams per side have been proven to improve chronic neck and back pain

3. If patients have been seen/treated by a doctor for chronic neck or back pain that will help

4. Insurance companies like to see history of chronic infections in the folds of the breast

5. Photodocumentation of size of breast and evidence of  shoulder indentations caused by bra straps are also important

All this being said the ultimate decision is up to your insurance company and the decision is theirs. If you are considering a reduction you should  carefully review your policy as many will have exclusion clauses that will not allow for payment. 

I perform lots of reductions and all my patients are extremely gratefull for the reduction in pain and discomfort and I encourage any patient considering a reduction to find an office that is willing to help provide insurance coverage for the reduction if it is indeed medically necessary.

Jonathan Weiler, MD
Baton Rouge Plastic Surgeon
4.5 out of 5 stars 16 reviews

Your breast reduction should be covered by insurance.

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Hi.

I hope this article is useful.


80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast Reduction Candidate?

+1

Thank you for the question and picture.

Based on your description and picture,  it may very well be that your lower back pain is related to the “bulging disks” rather than the ptotic breasts.  I would suggest that you be evaluated and treated for the possible spine issues first.

Based on your picture, your breasts are topic ( drooping);  at some point, you may benefit from breast reduction/breast lifting surgery.  Although this may help you with issues such as finding appropriate clothing, it may not necessarily help you with your lower back pain ( as discussed above).

It will be very important for you to educate yourself regarding the scars associated with breast reduction/lifting surgery. These scars may or may not be troublesome for you,  especially at your young age.

Most patients (If properly selected and who are doing the operations and the right time of their lives) accept the scars associated with breast lifting surgery as long as they are happy with the improvement in contour, size, and symmetry. This acceptance of the scars is the essential “trade-off” associated with many of the procedures we do.

Although it will not hurt to try, I am doubtful that insurance companies will “cover” your breast  surgery  given that  they are not too large given your frame/height.  Again, the major issue in your case may be breast position, more so than breast size.

It may be in your best interest to meet with well experienced board-certified plastic surgeons to discuss options.

Best wishes.

 

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 716 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.