I Am About 5"8 and Weigh 180. My Breast Size is a DDD or G. Will Insurance Pay for Reduction?

Document, document, document! Insurance companies will pay for a breast reduction IF the woman has neck, back, shoulder or breast pain, or rashes or macerations that require medical treatment.  They determine the amount to be remove based on body surface area.  You would have to contact BCBS for their requirements.  The disadvantage of having your insurance company pay for the procedure is meeting their weight requirements.  For example, if the weight requirements were 600 grams, you would go down 3 cup sizes and that would make you a C cup.  This may not look good to you and you may not be satisfied with the result.  In that case, you would be better off paying a plastic surgeon to reduce your breasts the way YOU want, rather that what the insurance company demands.

Best of Luck,

Gary Horndeski, M.D.

As a reviewer for Blue Cross/Blue Shield for many years, I can tell you that your surgeon will need to document back pain, neck pain, shoulder grooves from bra straps, rashes (intertrigo) beneath your breasts, and perhaps even numbness in your 4th and 5th fingers from bra strap pressure on the nerves to these fingers (in your lower neck/shoulder area). This list is subjective and virtually every breast reduction patient with large breasts has all if not most of these symptoms to some degree. That's the "easy" part.

Then comes the mathematical computation (the Schnur formula) that uses your height and weight to determine the exact minimum amount of breast tissue that MUST be removed in order to qualify for insurance reimbursement. For you, this weight is 606 grams per breast based on your stated height of 5'8" and weight of 180lbs. Since 1 pound is 454 grams, your surgeon MUST remove AT LEAST 1 1/3 pounds per breast or YOU will get the entire hospital, anesthesia, and surgeon's bill. This varies but can be 10-15 thousand dollars or more!

Many women who wear large bra sizes actually have more droopy breasts than large breasts, so it is critical to compare an actual breast implant weighing 600 grams (for your example) with one of your breasts, because once the 606 grams is removed, your breast size and shape is determined by what is left behind. I find that many women, after doing this simple test comparison, realize that they will require nearly complete mastectomies in order for insurance to "cover" their surgery. This is NOT a good solution, since the only recourse now that your breasts are too small for the rest of your body are breast implants (which you have to pay for yourself). So if you don't qualify, have only the amount of tissue removed that leaves you with pleasing and proportionate breasts, which may actually end up being a "cosmetic" breast reduction or full breast lift. Sure, you will have to pay for this, but it's significantly better than having to undergo two operations when the "correct" one is actually better!

Of course, if your breasts are truly as large as your bra size seems to indicate, your surgeon may be able to remove 606 grams or more from each side and still leave you with attractive proportionate breasts! Best wishes!

Insurance may cover breast reduction for some women. It depends on the patient’s breast size, body type, and symptoms. Most insurance companies have a formula based on your height, your weight, and how much your surgeon estimates will be removed. Usually removal of about a pound from each breast is required for insurance coverage.  Health care providers are mercenary about denying coverage for breast reduction. They don’t care if your clothes don’t fit or you can’t exercise. In my experience, they don’t even care about your pain and discomfort, much less psychological embarrassment. It all boils down to your height and weight versus how much breast tissue will be removed. You can’t necessarily pick your desired breast size or shape. To remove less than the insurance company’s formula requires places the procedure in the realm of cosmetic surgery. That means you pay the bill. Your surgeon should get a detailed medical history because some health- care providers demand a history of treatment for back pain to authorize coverage. I measure the breasts and often take photographs to be mailed with the insurance letter. If I don’t comply with the rules, the insurance provider— who holds all the cards—may not authorize paying for the procedure.  All the best of luck with this, "Dr. Joe" Gryskiewicz

 

You are most likely a good candidate for breast reduction surgery. Getting insurance to cover it is another matter. Most insurance companies have several different types of policies so it is possible some Blue Cross policies will cover while other may not. You should see a Board Certified Plastic Surgeon who can tell you if you would qualify and then would help you get preauthorization.Good luck!

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

You should be able to be considered for a breast reduction if you meet certain criteria. Call a Board Certified plastic surgeon or get a referral from your primary care doctor.


You may want to ask the surgeon's office ahead of time if there is anything else they would like you to bring (insurance information, name of primary care physician). For breast reduction surgery, it would be good to find out what criteria your insurance company requires to approve the surgery and have it available at the time of consultation. This includes:

Symptoms such as neck, back, shoulder pain, headaches, hand numbness, breast pain, rashes under the breasts, poor posture. Documentation from your primary care doctor of these symptoms Documentation that you tried 6 months of physical therapy to improve these symptoms Other requirements based on your insurance company's protocol Results of your last mammogram or other breast studies (if you had any)

 Based on your description you may be a good candidate for breast reduction surgery; it is one of the most patient pleasing operations we perform. If you are not there you may want to reach a long-term stable weight prior to surgery.

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 saying a well-trained/experienced board-certified plastic surgeon.  

 Prepare to be persistent.

Maybe.

There are many issues with respect to insurance.  Each insurance company is different, and each has its own rules with respect to "coverage."  You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

Either way, 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).

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.

I hope that this helps, and good luck,

Dr. E