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Tips for Getting Insurance to Approve Breast Reduction?

I am 5'7" and last weighed at 210lbs, yes I know I am over weight. My bust is 40 H. I have been working out at my apartment's gym for a few weeks now. I have lost some fat and gained some muscle, and after losing some weight I gained it back without gaining the fat back (so in other words it is muscle) my natural waist is measured (this morning actually) at 34" and my bust is measured at 48", but all my doctor is concerned about is my weight. not my true body fat percentage. Any tips on how I could get my insurance approve my breast reduction?

Doctor Answers 16

Insurance coverage for breast reduction

If you have H cup breasts and your insurance company considers this gigantomastia, rather than macromastia, the weight will not be an impediment to insurance approval. Every insurance company has different criteria. If your chest circumference is 48, then you may not be a 40H cup, but could be a 48 with a smaller cup size. For many insurers, the photograph will say it all. Additionally, each company has its own set of criteria. Some will require a prescribed body mass index. Others look for conservative medical management, such a chiropractic, pain medication, physical therapy, neurology, etc. prior to approving surgery. Become an educated insured and look up your carrier's requirements online. Then see a board certified plastic surgeon in consultation who knows how to navigate the insurance system and will advocate on your behalf.

New York Plastic Surgeon
5.0 out of 5 stars 17 reviews

Insurance Coverage

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

A Prior Authorization Letter From Your Plastic Surgeon Will Help to Get Your Breast Reduction Approved

Breast Reduction is often considered medically necessary by insurance carriers and is therefore a covered expense.  Before approval can be granted insurance carriers require prior authorization.  This is a time consuming process that may take months.
The process begins with a consultation, followed by a prior authorization letter to the patient’s insurance carriers. This letter should include documentation of the patient’s history, symptomatology,  pertinent physical findings, attempted non surgical management and anticipated amounts of tissue to be removed.
Supporting pictures as well as documentation of conservative management are also very important.  This might include documentation of physical therapy, chiropractic care, the use of specialized support bras and non steroidal anti inflammatory agents.
The amount of tissue removed is one of the more important criteria used by insurance carriers.  This number varies from insurance carrier to insurance carrier.  Its often part of a height weight index.  As a patient’s weight increases insurance generally require the removal of more breast tissue.
In your case, it would be unlikely for your insurance company to deny prior authorization for breast reduction.  The size of your breast would meet most insurance company’s weight removal criteria, especially if you have appropriate supporting documentation.
If your considering breast reduction surgery, consultation with a board certified plastic surgeon who has experience in this area would be helpful in obtaining prior authorization for this procedure.

Tips for Getting Insurance to Approve Breast Reduction

The key points to getting insurance coverage when the company has a policy which includes breast reduction are as follows:
Must have documented neck and back pain not relieved my physical therapy, medication, and properly fitted bras.  Evidence of shoulder grooving from bra straps. Intertriginous rashes near the inframammary fold. Finally photographs are usually submitted and these are very important to some carriers in deciding to cover the procedure.

Paul Vitenas, Jr., MD
Houston Plastic Surgeon
5.0 out of 5 stars 58 reviews

Tips for Insurance Approval for Breast Reduction

Here are some basics about Insurance Coverage Criteria for approval for Breast Reduction. 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 63 reviews

Breast Reduction - Insurance Coverage

It is nearly impossible to offer a guaranteed method of obtaining approval but if you have tried, and failed, a series of conservative techniques, then it may be reasonable to contact them.  You'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.  You should, of course, meet with a few plastic surgeons to see what they recommend, and make sure you're informed about the procedure and its risks so that you can proceed knowledgeably.

Then, it may require some persistence.  Start with contacting them via mail, and be sure to be involved in any followup phone calls, etc.  Hopefully, this will wind up being successful and get you the results you want.

I hope that this helps, and good luck,

Dr. E

Breast Reduction Insurance Coverage?

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.

Insurance approval for breast reduction

I recommend that you go on line and download your insurance carriers criteria for breast reduction surgery. If you do not meet these criteria, I can guarantee they will not preapprove your surgery.

In general, many insurance companies will require that you have failed conservative treatment of your back, neck and shoulder pain before approving surgery. This includes no improvemnt in your symptoms with medication prescribed by your family doctor, no improvement after seeing a chiropractor/ physical therapist or after losing weight. A letter from your family doctor or chiropractor/ physical therapist would also help.

You will also need to see a board certified plastic surgeon who will need to submit a letter and pictures to your insurance company seeking approval.

Good luck.

David A. Robinson, MD
Munster Plastic Surgeon
4.5 out of 5 stars 22 reviews

Breast reduction insurance coverage

Breast reduction is usually covered by insurance when the surgery is performed as part of a medically mandated procedure to treat neck, back, or shoulder pain or other problems related to the spine. Recently, managed care has adopted stricter standards for coverage, so these problems have to be thoroughly documented in writing by your primary care physician and plastic surgeon. They may also have to submit photographs. Even then, you may be required to seek a second opinion from a chiropractor, physical therapist, or orthopedic surgeon.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.5 out of 5 stars 8 reviews

Insurance to approve breast reduction

TRY by seeing a boarded plastic surgeon who will then submit to your insurance company a predetermination letter with photos of your breasts. Other information will also be included. THAN IT IS A WAIT. It is like a game of who's it. Keep calling the insurance company, become a pain to them. Keep asking why, what, and when. Hopefully you will be approved. 

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.