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?

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14 Doctor Answers | Asked by madam_squeak in anaheim,CA

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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... more

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... more

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.

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... more

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... more

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... more

Breast reduction

It is always better to lose weight to get down to a weight that is appropriate for your height. As for insurance coverage each insurance company has different criteria for approval and you would need to check with them.

Steven Wallach, MD

12 reviews

Manhattan Plastic Surgeon

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... more

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... more

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.