Seek Second Opinion Regarding Breast Reduction Insurance Coverage?

Hello. I am 28 years old and am about 5'5" tall and weight around 180lbs which I have lost a lot of weight. My breast size is a 38DDD and I have a lot of irritation under them and a lot of shoulder and back pain.

I recently hurt my back the doc said it was a joint in my lower back the pivots and sticks. I asked about Breast reduction and he said medicaid won't pay for it because I have not complained enough or went to a doctor enough. Should I find another doctor?

Doctor Answers (12)

Insurance coverage for breast reduction mammaplasty

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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


Houston Plastic Surgeon
4.5 out of 5 stars 117 reviews

Insurance

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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.

Sugene Kim, MD
Houston Plastic Surgeon
4.5 out of 5 stars 38 reviews

Second opinion for breast reduction

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Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier.  Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front.  Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days.  The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.

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Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 14 reviews

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Second Opinion helpful for Breast Reduction Insurance Coverage

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Yes, the more consultants that recommend breast reduction the better your chances for coverage. Here are some tips for getting coverage:Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company.  In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc. They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems.. Contact your individual company and request their specific Criteria.

Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.

Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :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 though insurance criteria are becoming more and more restrictive

 

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 45 reviews

Breast Reduction - Insurance Coverage

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This is clearly a question that comes up frequently.

Whether or not an insurance company will pay for breast reduction surgery depends on many factors, but chief among them are your height and weight, as compared your breast size now and what size you would be reduced to.  In your case, an insurance company might want you to lose some weight first and, at that point, you may not be able to have enough of a reduction to balance both their requirements and what you would want and need for your frame.  That is a decision that has to be made jointly between you and your surgeon.  Symptoms including neck, back and shoulder pain, and bra strap grooving typically do contribute to the insurance company's likelihood of approval but they may not be enough to justify it on their own.

I hope that this helps and good luck,

Dr. E

Alan M. Engler, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 150 reviews

Breast Reduction Insurance Coverage?

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Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.

Based on your description you may be a good candidate for breast reduction surgery; for  physical and emotional reasons.
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 715 reviews

I agree with Dr Rand.

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Go to one of the teaching hospitals in your area and see if they will take Medicaid.   The payments do not cover the costs of doing the surgery in private practice.  Good Luck!

Grant Stevens, MD
Los Angeles Plastic Surgeon
4.5 out of 5 stars 67 reviews

Insurance coverage for breast lift or breast reduction.

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Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
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.

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

Breast reduction by Medicaid

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Most top plastic surgeons won't do Medicaid reductions anymore because the payments are exceptionally low, even lower than the cost to the doctor to do the surgery. Consequently, since there are many excellent plastic surgery training programs in NY ie. NYU, Cornell, you should go to one and seek care there.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 48 reviews

Breast reduction and insurance

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Breast reduction can often be covered by insurance. If you have significant neck and back pain and yaour breast are very heavy, you may get coverage. You need supporting documentation that your symptoms have not improved with conservative management.

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.