I'm 5'7 243lbs and I Would Like a Breast Reduction.. Bra Size is Now 42 L, Wondering if my Insurance Will Cover? (photo)

There are indentations in my shoulders, my posture is bad, I get rashes in the summer time under my breast and back & neck pains after my workouts. I also get pains that shoot from my shoulders down to my arms when I workout because of the weight of my breast. I know I would likely have to lose weight for my insurance to cover it, but it's a struggle. Now I do workout and my goal is to lose 20 before my consult. Do you think that is enough for my insurance to cover it. Here's a pic of me now.

Doctor Answers 8

Medical necessity and insurance coverage for breast reduction surgery

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From the symptoms you describe you are certainly a good candidate for a breast reduction.  Insurance coverage is a different story.  You will need to be evaluated and your plastic surgeon can submit a letter to determine medical necessity.  

Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Breast reduction and insurance

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It is getting tougher and tougher to seek breast reduction through insurance. Each insurance company also has different criteria.  Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Will Insurance Cover Breast Reduction

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You seem to be a good candidate for breast reduction surgery. Be sure to have all your symptoms documented by your doctor and  anything else you have tried to alleviate your discomfort, such as physical therapy, special bras, analgesics etc. It is difficult to know in advance what your insurance company will require. Each company seems to have its own guidelines.  If your insurance requires you to be at certain weight, you may not know what that is until you apply for coverage. See a Board Certified Plastic Surgeon who specializes in breast reduction surgery and he/she will know how to request authorization from your insurance company. If you get denied, ask your surgeon to file an appeal. The insurance company then has a medical doctor contact your surgeon  for further evaluation. I have gotten several patients approved this way. Good luck!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 81 reviews

Insurance Coverage

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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

Insurance coverage of breast reductions is unpredictable.

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Each policy will define requirements for payment for breast reduction if it is covered at all. This would require communications the insurance company to ascertain the conditions for coverage.

More than likely

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Most insurance companies will cover breast reduction in a patient like you.  Seek a consultation with a board certified plastic surgeon and they will collect you informationk, take pictures, and submit an inquiry to your carrier.  It will be helpful to have notes from any treatment you have had regarding back pain, rashes and any other problems related to your breast size. If you have had treatement such has physical therapy for the back issues this is also helpful. Some insurers will require you to loose some weight prior to approval.

Scott Tucker, MD
Winston Salem Plastic Surgeon
5.0 out of 5 stars 32 reviews

Candidate for Breast Reduction

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Thank you for your question and photo.  You are a candidate for brreast reduction.  It will help to reduce you breast symptoms including back and neck pain, rashes and improve your ability to exercise and find more supportive bras.  Whether or not it is covered by insurance depends on your plan.  Some plans exclude breast reduction. Call your insurance company and ask about your coverage as well as the coverage criteria.  Take that with you to your consultation.  Best wishes.

Breast Reduction Candidate?

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Based on your description you may be a excellent candidate for breast reduction surgery at some point; it will be in your best interest to drop  additional weight first.
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 are seeing a well-trained/experienced board-certified plastic surgeons.  Ask to see lots of examples of their work.

When dealing with health insurance companies, be prepared to be persistent.  In the end it will be worth it;  breast reduction surgery tends to be one of the most patient pleasing operations we perform.

 Best wishes.

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.