How to Succsesfuly Get Insurence to Cover Breast Reduction?

putting in an insurence claim for breast reduction, I am 5'3, 130lbs and a 32DD. What are my chances of success? My doctor agreed right away and started the claim, I have done 3 years of physical therapy with no such luck of back strengtheng etc.. My usual weight is 117-120, but with so much pain exercising is not the easiest. Is there anyway I can succsessfuly be granted this procedure?

Doctor Answers (11)

Insurance coverage for breast reduction

+3
Insurance companies want to see proof of conservative management, such as physical therapy, but also have standards for the amount of breast tissue that must be removed. In NY, that amount is typically 500 grams of tissue per breast. You would need to see a board certified plastic surgeon in consultation, bring your treatment records, have him apply for preauthorization and then see what the insurer says. They are usually more cooperative with in network physicians as there is a substantial saving if the patient stays in network. If your carrier denies the case, there will be opportunities for internal and external appeals. The authorization process takes about a month so get started and hope for the best!


New York Plastic Surgeon
5.0 out of 5 stars 11 reviews

Breast Reduction and Insurance coverage.

+3

Thank you for the question.

It sounds like you are dealing with  breast hypertrophy along with the physical and psychosocial consequences of this diagnosis. In other words, the breasts are too large for the frame causing  both physical and psychological distress.

Based on your physical description you may be an excellent candidate for breast reduction surgery that will hopefully be covered through your insurance plan. Unfortunately, there is no way of knowing whether a specific insurance company will cover the procedure until you have submitted the necessary “pre-authorization paperwork” and supporting documents. The more support you have from your other physicians/therapists the better.

Although there are certainly hoops to jump through, most patients find it worthwhile given the expenses associated with breast reduction procedure otherwise. It is one of the most patient pleasing operations we perform.

I hope this helps.

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

Breast reduction and medical insurance

+2

Breast reduction continues to be an extremely common procedure in the United States.  In my practice, the majority of breast reductions are paid for by insurance companies.  Each insurance company is different in regards to what they deem medically necessary.  Typically it has to be proven that severe symptoms exist such as neck, shoulder and back pain, rashes under the breasts, shoulder grooves, and even arm numbness.  In addition, it must also be shown that numerous non-surgical (conservative) measures have been tried and that they were unsuccessful.  This includes pain medications, powders, physical therapy, weight loss, and special bras.  Frequently, we take photos of patients to include with our submission to the insurance company to better document the gravity of the situation.  The more documentation the better.  Frequently is it helpful to get supporting documents from a primary care provider as well as a physial therapist or chiropractor.

Kelly Gallego, MD, FACS
Yuba City Plastic Surgeon
5.0 out of 5 stars 33 reviews

You might also like...

Insurance coverage for breast reduction

+1

Insurance coverage is a contract and each contract varies--even from the same insurance company. And there is a lot of fine print in most health insurance contracts. In general, however, for insurance to cover any surgery, it must be medically necessary and for breast reduction, many companies also have a minimum amount of tissue that must be removed. Your board certified plastic surgeon is in the best position to help determine whether you meet your insurance companies criteria by getting a pre-authorization for the surgery. Unfortunately, this is not a guarantee that they will cover it, but it is a good indication. They almost certainly won't cover it without a pre-authorization. Good luck.
 

Margaret Skiles, MD
Sacramento Plastic Surgeon
3.5 out of 5 stars 10 reviews

Insurance coverage for breast reduction

+1

Thanks for your question as this is a commonly asked question.

 

The inusrance company will cover breast reduction if;

You have had physical symptoms related to heaviness of the breast tissues.

Conservative and medical treatment has not been successful.

History of back pain, shoulder pain, or skin rash.

 

Discuss this in person with a Board certified plastic surgeon as they would be able to help you with gathering the necessary documentaion in conjuction with your OB/GYN and your primary care physician.

Something to remember is that the insurance companies require 350-500 gram of tissues to have it being covered.

Hope this is helpful.

Dr. Sajjadian

 

Ali Sajjadian, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 120 reviews

Insurance company approval for breast reduction

+1

Insurance companies have different criteria of eligibility for coverage for a breast reduction. Furthermore, some insurance plans from these same companies exclude coverage for this surgery - so you will need to find this out.

It appears that your breasts are significantly enlarged and in the range where approval may be a possibility. Most insurance companies require a minimum gram weight of breast tissue to be removed and this amount is often based on your height and weight. Furthermore, documentation of symptoms is needed. Letters from your primary care doctor, a physical therapist or even a chiropractor can be helpful. Failed physical therapy also is important for many companies.

See a board certified plastic surgeon who can fully evaluate you and then seek authorization for the breast reduction surgery.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 20 reviews

You can probably get insurance coverage for breast reduction.

+1

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, Insurance coverage

+1

Each insurance carrier is different in what they require to cover breast reduction. And groups of policies inside the same insurance company may differ as well. Let your surgeon's office handle this for you, they are used to it. In the meantime the person in the doctor's office that does the insurance work shoulod be able to gibve you at least some idea of the likelihood of your company covering your surgery. Good luck, it sounds like you would definitely benefit from the procedure.

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

Gettin Insurance Coverage for Breast Reduction

+1

Each insurance company has their own criteria for qualifying for coverage. Most require the needed amount of breast tissue to be removed is 500 grams per breast and that is usually a DD cup. They also want documentation of physical therapy, medications tried, good support bras, anything you have done that did not help. It sounds like you would be a good candidate, as long as your insurance does not have an exclusion for breast reduction, you should get approval. If for some reason you are denied, ask your doctor to appeal your case. It will then be reviewed by a physician who will probably call and speak to your doctor. I have done this for several patients with success, Good Luck!

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

Insurance Coverage for Breast Reduction

+1

Here is the advice I share with my patients:

1.  Gather documentation.  Letters from your primary care physician, OB-GYN, orthopedic surgeons, or chiropractors are helpful, as is documentation of failure of physical therapy. 

2.  Take pictures.  If you have ever had a rash below your breasts, get a photo.  A letter from a dermatologist can also help.

3.  Check with your insurance company.  It used to be standard that 500 grams of tissue had to be removed for a breast reduction to be covered by insurance.  This made it very difficult for a petite woman like yourself to get coverage.  Many insurance companies are now using a formula based on your body mass index (BMI).  If that is the case, you can give this formula to your surgeon and have her see where you would fall in the calculations. 

4.  Be the squeaky wheel.  In some cases, you may need to appeal and pester your insurance company to have a denial overturned.  While this doesn't always work, I have seen cases approved by a very persistent patient that was originally denied.  You can also ask your surgeon to do a peer-to-peer discussion with the insurance company if you get a denial.

Best of luck to you!

Danielle DeLuca-Pytell, MD
New York Plastic Surgeon
5.0 out of 5 stars 4 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.