Doctors Say I Need a Breast Reduction For My Health, But My Insurance Keeps Saying No. What Can I Do?

I Am 5'5 with a Size 42h/i You Think I Will Get Approved for Br Surgery? i am overweight but am constantly trying to lose it (no thanks to deprovera birth control shot).i have united health care insurance and was denied by them in all three stages. im confused as to why. every doctor i've com into contact with has said this surgery needs to happen. i have receipts for a new bed i had to purchase, bras, gym memberships, personal trainers, photos, etc. i dont understand why im still getting told no. and is there special funding?

Doctor Answers 6

Doctors Say I Need a Breast Reduction For My Health, But My Insurance Keeps Saying No.

Are you relying on your insurance company to make your health care decisions? If so, you will receive very little care. Their only interest in your health is to determine how little they can pay and still meet their contractual obligations. They set limits and you have to meet them or they don't have to pay. If you need a reduction, get one and pay for it. It will be one of the best things you will ever do for yourself. At least 1/3 of my reduction patients pay for their surgery because their insurance company sets the bar too high for many patients to receive insurance coverage.

Portland Plastic Surgeon
5.0 out of 5 stars 27 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

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.7 out of 5 stars 210 reviews

More insurance companies are not including breast reduction as a covered procedure.

Whether a breast reduction should be covered by insurance is a philosophical issue.  Patients are helped functionally most of the time but, on the other hand, it is an operation that can be budgeted for and is certainly not an emergency.  Furthermore, deductibles will continue to get so high that patients will have to pay cash as a matter of practicality.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.7 out of 5 stars 35 reviews

Insurance coverage for breast reduction

You haven't provided a weight and my guess is that you aren't thin. Typically, a case of gigantomastia will not have weight restrictions. However, the type of documentation you have provided to the insurance company is not what it is looking for. They don't want to hear about personal trainers, beds and bras. What they do look for is proof that a comprehensive physical therapy program did not improve whatever pain pattern you are claiming, that an orthopedic surgeon has recommended the surgery, that MRIs and x-rays demonstrate lordosis for the spine attributable to the breasts, etc. If you believe that your weight loss is impeded by your birth control method, perhaps you should consider an alternative.

Robert L. Kraft, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 41 reviews

Breast Reduction and Insurance Coverage?

Thank you for the question.

Based on your description you may be an excellent candidate for breast reduction surgery; it is one of the most patient pleasing operations would perform. Also, you may benefit from professional assistance from  physicians, personal trainers and/or nutritionists to help you with your weight loss program.

It may be that with ongoing weight loss your insurance company will authorize the procedure. Unfortunately, it can be quite difficult to obtain this authorization (as you have found out).  Sometimes appealing  the health insurance (with the help of your plastic surgeon) may be  effective.

If these measures do not work, then working with well experienced board-certified plastic surgeons' offices to help you with financing may be your only/best option.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 reviews

Breast Reduction - My Insurance Keeps Saying No

Each insurance company has its own criteria as to what they will consider a "covered" procedure but with a 42H/I bra size, my guess is that they feel you are too heavy for your frame and they would like to see you lose weight first.  Or, at least, that you've failed several attempts at conservative therapy (weight loss, chiropractic care, etc).  I would suggest that you meet with your plastic surgeon and try to work out some sort of a plan that addresses all of these issues.  In general, the surgery is more likely to be "covered" if you can indicate that specific symptoms, such as neck, back and shoulder pain, bra strap grooving, and intertrigo, would be relieved by the surgery.  Hopefully you will then be able to get approval.

I hope that this helps, and good luck,

Dr. E

Alan M. Engler, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 125 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.