Breast reduction coverage
You may want to read my answer here so that I avoid being repetitive:
In most instances with private insurance, your doctor can submit a letter of predetermination of benefits to ascertain if your procedure is covered. However, Medicaid does not accept or review these letters so that is a moot point. In general, its sounds as if the amount of reduction would be reasonably covered in your particular situation.
Insurance criteria for Breast Reduction coverage
Every insurance company has specific criteria that they use to determine the medical necessity of a breast reduction. This is based on multiple factors and differs from insurance company to insurance company (and from state to state in the case of government plans). The things that they will look at are primarily the symptoms you are having related to your large breasts, the different non-surgical remedies you have tried (eg chiropractor, medications, physical therapy, etc.), your height, weight, and an estimate of how much weight is to be resected. The place to start is with a consultation with a board-certified plastic surgeon who can review whether you are a good candidate for breast reduction surgery.
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.
Breast reduction insurance coverage
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 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 working with a well-trained/experienced board-certified plastic surgeon.
Insurance and breast reduction
Insurance does not always cover a breast reduction. The best thing for you to do would be to call yoru insurance company and ask for their criteria to approve them. Then seek a doctor that will accept Medicaid.
Insurance coverage for breast reduction.
Insurance Coverage for Breast Reduction
Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
Contact the doctor
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.
1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.
2) Very big reductions (like from an F cup to a C cup) will usually be covered.
3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.
4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.
5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.
6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.
7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.
8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.
9) Don't give up. If the first request is denied, demand an appeal.
10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.
Helpful?Last modified 24 days ago
Insurance coverage for breast reduction
Insurance coverage has gotten more difficult over the years. When I started my practice, most of my reductions were covered by insurance. Now most are not.
Lifting the breast and reducing the size helps with back pain, neck pain, shoulder notching, rashes and infections of the skin under the breast, and posture. It also helps with ease finding clothes and ability to exercise.
Check with insurance to see if “reduction mammaplasty” is a covered surgery with your plan. All plans are different, even within the same insurance company.
Generally a minimum reduction of at least two breast cup sizes is necessary. Many companies adhere to the Schnur Scale to see the amount which must be removed. With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered. If she weighs 160, she would need about 450 grams per breast. Liposuctioned fat cannot be applied to this total. For those of us who do the vertical breast reduction (the short scar, "lollipop" not the "anchor" scar), the amount of tissue I directly cut out is less than it used to be.
Having supportive letters from your primary care doctor, chiropractor, physical therapist, or other doctors is helpful. If you have taken medications for skin infections or pain medications for neck and back pain, document it. Many insurance companies require some form of "non-surgical" treatment for your symptoms before they will cover the surgery.
Good luck. I think it is a great surgery. Going from an H to a C/D may get qualified. It all depends on the amount removed.