What Are the Steps to Getting a Breast Reduction Approved by my Insurance?

Age: 20 Height: 5'2 1/2" Weight: 120 lbs. Bra size: 32 H I experience a lot of back pain especially in my shoulders. My bra straps often dig into my shoulders. I often feel pulling on my chest area because they are so heavy. I am concerned as to what size they would take them down to, what scarring there could be, what complications could occur, and what my experience would be post-op. I am also a recovering addict so pain medication is something I would have to refuse post-op.

Doctor Answers (7)

Breast Reduction Concerns…

+3

Based on your description you may be a good candidate for breast reduction surgery; this operation 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.

Before undergoing the breast reduction procedure it will be very important to communicate your size goals with your surgeon.  Most patients wish to achieve  enough of a reduction to help with their symptoms while remaining proportionate with the remainder of their torso. 
With the goal of improving communication with my patients I find the use of photographs of “goal” pictures (and breasts that are too big or too small)  very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" means different things to different people and therefore prove unhelpful.
 Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.

In regards to postoperative pain management, your plastic surgeon will  likely be able to help with the use of nonnarcotic medications (as much is possible).

 I hope this helps.


San Diego Plastic Surgeon
5.0 out of 5 stars 722 reviews

Breast Reduction

+2

See a plastic surgeon -- talk to them , they should take photos and then you can contact your insurance company with them. If you have consults from internist showing back pains it might help. The insurance companies are becoming more difficult.

William B. Rosenblatt, MD
New York Plastic Surgeon
4.0 out of 5 stars 9 reviews

Steps to insurance approval of breast reduction

+2
The criteria for your insurance company should be posted on its website. Many insurers now require proof of at least six months`conservative management. However, in cases of gigantomastia, some carriers waive this. A great deal of the information you are seeking can be found on, the site for the American Society of Plastic Surgeons, as well as on RealSelf. In terms of the drug use history, you may not be a happy camper for a couple of days, but extra strength Tylenol may be effective. You may want to research biofeedback, aromatherapy, etc prior to your procedure.

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

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Surgeon Needs To Communicate With Ins. Co. For Reduction Approval

+2

It certainly sounds as if you would benefit from a breast reduction.  You should obtain a consultation with a board-certified plastic surgeon who can then communicate with your insurance company to get prior approval.  Congratulations on your recovery!

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

Insurance

+1

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 coverage

+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.

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

Breast reduction coverage by insurance

+1

You should have a consultation with a board certified plastic surgeon.  After He/She has examined you and established medical necessity, your insurance company is contacted for preauthorization.  Discussions of risks and benefits of surgery including postoperative size needs to be done in person with your surgeon.  Best of luck.

Kevin Tehrani, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 40 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.