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I am a 23 year old female, i am 5'4 and weigh about 133 pounds. Would Insurance Cover My Breast Reduction?

I am a 23 year old female, i am 5'4 and weigh about 133 pounds.Before i got pregnant my breast size was a 34c. Then once i had my child and started breast feeding my breast grew to a very heavy 34DD. Even after i was done breast feeding and losing all my "baby weight" i still have 34DD breasts! And to top it off my left breast is significantly large than the right one! I have developed a horibble hunch back and have constant neck and shoulder pain.

Doctor Answers (10)

Breast reduction insurance coverage

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Most medical insurance policies cover breast reductions, but they typically require that a certain weight of tissue be removed from each side to qualify.  In many cases the insurance may only cover a portion of the costs.  You should consult with a plastic surgeon who is an expert in breast surgery to understand your options.


Los Angeles Plastic Surgeon
5.0 out of 5 stars 19 reviews

Insurance coverage for breast reduction

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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 117 reviews

Insurance and Breast Reduction

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Based on your measurements you seem to need a breast reduction. Getting breast reduction covered under insurance is very difficult. In fact getting them to tell you, as the consumer, the number of grams needed to get coverage will be nearly impossible. I suspect in the end it will have to be paid out of pocket.  The insurance frequently places the restrictions without any medical substantiation. I have had many difficulties with my own patients getting coverage. The best way to get coverage is to call your insurance company...remember you are the consumer.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 15 reviews

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Body surface area determines reduction coverage

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You are 5'4 and weigh 133 lbs, so your body surface area is 1.64 meters squared.  If your insurance in with Aetna, they will require 495 grams removal.  At size 34, each 100 cc's is 1 cup size change.  You will have to go down 5 cup sizes to meet criteria that would end up a size A.  It is most likely that your insurance company will not cover your breast reduction since you are only a 34 DD.  They really do not care if you have neck, back or shoulder pain or are asymmetrical.  You will NEVER meet their criteria.  Your alternative is to pay cash for the procedure yourself.

Best of Luck,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
5.0 out of 5 stars 125 reviews

Breast reduction

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Photos would help,a lot in evaluating your case. Insurance companies have certain criteria for covering breast reduction surgery, including symptoms as back, neck and shoulder pain.  They almost always require a certain amount of breast tissue be removed from each breast, usually around 400 grams, or about a pound from each breast.  You need to go through the pre-authorization process. this involves a consult with a plastic surgeon who will send a letter and photos to your insurance company.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 11 reviews

Breast Reduction Candidate?

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Thank you for the 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  working with a well-trained/experienced board-certified plastic surgeon.
 

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 726 reviews

Will Insurance cover my Breast Reduction?

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I encourage you to meet with a board certified plastic surgeon who accepts your insurance and see if he believes you are a good candidate, then you will have to submit his recommendations to your insurance company and see if they agree, it can be a very difficult process to gain approval , but I encourage you to try.

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

Insurance coverage for breast reduction

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Each insurance company has it's own criteria so the first step would be for you to review these on the insurer's website. This will tell you what hoops you will have to jump through to get the procedure approved. Most insurance companies require proof that conservative medical measures did not improve your back pain, at a minimum.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 11 reviews

Insurance Coverage For Breast Reduction

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Although there is a lot of variance among onsurance companies regarding coverage of breast reduction, it sounds as if you should be covered, unless your policy has an outright denial for coverage.  Obtain a consultation with a BC plastic surgeon who can communicate with your ins. co. for you.

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

Would Insurance Cover My Breast Reduction?

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Medical insurance frequently covers breast reduction surgery, but depending on the carrier they will have several stipulations that need to be met, the most important is how much weight will be removed from each breast. They sometimes require notes from your primary care doctor that the excess breast weight is causing physical symptoms, and some require a trial of physical therapy. Understand, all these are time wasters because nothing short of surgery is going to relieve your symptoms. The only way to know whether or not you are covered is to have a consultation and let the doctor communicate to the insurance what weight is expected to be removed from each breast. The insurance carrier will then send him a letter of authorization or denial. If denied you can appeal.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 13 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.