What is the Criteria for a Breast Reduction to Be Medically Necessary?

asked 9 months ago by anon
Latest answer by Fredrick A. Valauri, MD
Question viewed 265 times
Tags: back, breasts, shoulder, back pain, breast size, candidate, insurance, outcome, pain, reduce, reduction, results, shoulder pain

What degree of back and shoulder problems/pain are considered breast reduction reasons for medically necessary according to most insurance options? How much of the problem is alleviated by such a surgery?

5 answers to What is the Criteria for a Breast Reduction to Be Medically Necessary?

Will My Breast Reduction be Covered?

Whether breast reduction surgery is covered or not varies from company to company depending the policy whihc might exclude coverage for all, but extremely large breast reductions. Typically they will request documentation of symptoms such as neck pain and back pain, and photographs, as well as a trial of physical therapy and weight loss, and an anticipated insurance mandiated minimum amout of breast tissue to be removed. This information will be reviewed and often authorization is... more

Fredrick A. Valauri, MD
New York Plastic Surgeon

www.drvalauri.com

Criteria for Breast Reduction to be Medically Necessary

Most insurance companies determine eligibility by how much tissue is to be removed, usually a minimum of 500 grams per breast. Usually a woman needs to be a DD or larger. Then the insurance company wants to know if having large breasts is causing back, neck and shoulder pain. they want to know what measures you have tried so far to relieve these symptoms, i.e. physical therapy, good support bras etc. Your surgeon will know how to request pre-authorization.Good Luck. more

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon

www.dr-delgado.com

Breast reduction insurance coverage

It is important to rule out other sources of neck and back pain prior to proceeding with breast reduction surgery; otherwise you may be disappointed if the symptoms persist despite having had the surgery. If your symptoms are related to large breasts then the chances that you will be please with results of surgery (and the relief of symptoms) are very high. The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The... more

Tom J. Pousti, MD
San Diego Plastic Surgeon

Medically Necessary Breast Reductions

Although it varies among insurance carriers, most companies require documentation of syptoms (pain in the neck, back, or shoulders and rashes on undersurface of breasts, for example). Most companies use the Schnur graph to determine the amount of breast tissue which needs to be removed in relation to body surface area. Many also require a trial of "conservative therapy" which never works in the case of true breast hypertrophy. As far as resolution of pain, many... more

John Whitt, MD
Louisville Plastic Surgeon

Insurance coverage for breast reduction.

Insurance Coverage for Breast Reduction 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... more

George J. Beraka, MD
Manhattan Plastic Surgeon

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