Do you have any tips for getting insurance to approve a breast reduction?

Most insurance companies don't factor in muscle mass.  Most use some variation of the Schnurr formula which calculates your BSA body surface area, and then each company has a certain number of grams required. In many ways, this is fair to most.  Little tiny women have a smaller grams requirement than big women, but it is somewhat proportional. Ask your plastic surgeon to seek pre-approval for your breast reduction. Most are approved. For the few that are not, you can calculate how much weight you might need to lose to get approval, or with some plans, you might find the requirements too strict.  In some cases, it may make sense to seek a cosmetic, or cash pay rate.  

Thank you for your question.
Make sure you have documentation supporting a necessity for a breast reduction. Shoulder grooving, neck/back pain, etc. Family physician and gynecologist can help out with this. Best wishes!

When seeking insurance approval for a breast reduction, it's essential to be proactive and well-informed, as each insurance plan has its own specific criteria for coverage. Typically, insurance companies require documented evidence of symptomatic macromastia.
*What is symptomatic macromastia?* This condition often results in symptoms such as chronic back, neck, and shoulder pain, skin rashes or irritation underneath the breasts, difficulty finding well-fitting clothing or bras, and limitations in physical activity. Women with symptomatic macromastia may experience significant emotional distress due to the physical discomfort and the impact on their daily lives. In many cases, breast reduction surgery is considered a treatment option to alleviate these symptoms by removing excess tissue, reducing breast size, and improving both physical comfort and overall quality of life. Insurance providers may cover the surgery if it is deemed medically necessary, based on the presence of these symptoms and other documented factors.
*What needs to be documented?* Providers need to build a strong case for medical necessity. This means documentation of failure of conservative treatments, such as weight loss, physical therapy, pain management, and medication for symptoms like neck, back, or shoulder pain. In addition, many plans require a certain amount of tissue removal (usually based on the Schnur Scale which considers body weight, body mass index, body surface area), although this can vary depending on the insurer. It’s important to work closely with your primary care doctor, who can document your attempts at non-surgical treatments and provide a referral for physical therapy, if applicable.
*What’s next?*You should consult with a plastic surgeon who specializes in breast reduction. The surgeon will assess your condition and measure the amount of excess tissue, which is important when submitting to insurance. Often, the surgeon will also provide supporting letters, detailing your symptoms and the need for surgery. It’s also a good idea to gather additional supporting letters from other healthcare providers, such as a physical therapist. By carefully following these steps and ensuring all documentation is thorough, you will maximize your chances of obtaining insurance approval for the procedure.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

In Australia, this procedure is often deemed medically necessary, and therefore there is an associated Medicare item number. Therefore, private insurance rebates will apply, assisting with the overall costs. The main contribution will be towards the hospital fee. However, the total price you pay even with insurance will depend on the specifics of the surgery. This is because we cater each operation to the patient.

Great question and I mimic what Dr. Hammoudeh said.  The key is to document (have receipts or photos) every medication or powder/cream you may have purchased if you have rashes under your breasts.  Document or obtain any office notes from your PCP indicating issues with shoulder grooving, back and neck pain.  Some insurance carriers also want proof that you tried dieting and exercise to reduce the weight of your breasts for a certain period of time (ie. 3-6 months). All this and they will still require a letter of necessity from your doctors and photographs.  Not to mention they require a weight of tissue removed during surgery which may not be either feasible or what you inevitably desire as your overall size.  Given that there are so many moving parts, consulting with a plastic surgeon is best to determine your goals, expectations and likelihood that your reduction will be covered for insurance.  Oh, and hearing back on whether the insurance company covers the procedure could take several weeks to a few months, so timing your surgery and consultation around your schedule is key.  Hope that helps!

Hi and thanks for your question.  Every insurance plan has its own specific criteria for what they consider medically necessary in regards to a breast reduction, despite what your doctor’s opinion may be.  It’s the patient’s responsibility to be proactive and contact their own plan in advance so that they can be familiar with these criteria and provide their doctor with the relevant information (for example, if you’ve been treated by a physical therapist, or if you been prescribed medication for rashes).  Don’t expect your doctor to know the details of what your specific individual plan considers medical necessary, your doctor can provide their medical opinion but ultimately the insurance company decides if they agree — every plan is different and has its own rules.  If you want to get your insurance involved stay ahead of the game and find out their specific requirements in advance by contacting them yourself.  That way there’s no surprises.A visit to a plastic surgeon's office will help you to understand if you're a candidate for the procedure, and what aesthetic outcomes are realistic in your particular case.  In order to get a qualified, ethical, and expert opinion on your surgical options and expectations, always schedule an in-person office consultation with a plastic surgeon certified by the American Board of Plastic Surgery.
Best of luck,
Keith M. Blechman, MD
New York, NY