Am I a Candidate for Breast Reduction at Insurance Cost?

I am 5'1" 125 lbs and wear a 34 E or 36 DDD. I have back, neck and sholder pain daily. Most recently I am experiencing severe pain through my breast going to the nipple intermitantly. What do I need to do to get my insurance to cover the cost of breast reduction?

Doctor Answers 10

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

Breast Reduction Eligibility

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Eligibility for breast reduction is based on distinct criteria, which happen to vary between insurance carriers. You can contact your particular carrier to find out what the criteria are exactly. In general, patients first must have breasts that are too big and require a defined minimum amount of tissue to be removed. See the link below which shows reduction criteria based on your height and weight. If you meet that breast size criteria, then you will also need to have additional symptoms such as back pain, shoulder pain, and rashes in the folds under your breasts.

Kevin Brenner, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 23 reviews

Breast Reduction Via Insurance

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All insurance companies are different and have different criteria that needs to be met in order for them to even consider covering the cost of your surgery.  Check with your insurance company to see what they require and see a Board Certified Plastic Surgeon who works with insurance companies for your consultation and physical exam.  From there, they will possibly take photos, code your visit and submit it to your insurance provider and wait for approval or denial.

Andrew Smith, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 24 reviews

Breast reduction

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The answer to that question depends on your insurance company. Some insurance companies will deny reductions even in the most obvious of cases. I would recommend calling a local plastic surgeon and discuss the situation with the office staff. They will have more insight into the insurance company in your area.

Breast reduction and insurance

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I think that for you it is important to call your insurance company and ask for their criteria to approve the surgery. Each insurance company is a bit different.

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

Am I a Candidate for Breast Reduction at Insurance Cost?

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The only way you can get an answer to your question is to consult with a plastic surgeon that does breast reductions, have him examine you and then he will attempt to preauthorize the surgery for you.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 reviews

Insurance coverage for breast reduction

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Based on the information you provided, it sounds like you would be a good candidate for breast reduction surgery.  To determine insurance benefits, you should first contact your insurance company requesting a written copy of their criteria for breast reduction and also check your benefits to make sure breast reduction is not excluded from your policy.  Once you have that information, schedule an appointment with a board certified plastic surgeon who will write a letter of pre-determination on your behalf.  If you have letters from physical therapist, chiropractors, or other physicians that recommend breast reduction surgery to alleviate your pain and symptoms, your plastic surgeon should include them when obtaining pre-dertimination as it will help your case. Good luck.

Richard A. D’Amico, MD, FACS
Englewood Plastic Surgeon
4.9 out of 5 stars 25 reviews

Insurance Coverage for Breast Reduction?

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From your description you sound like an excellent candidate for insurance to cover your breast reduction surgery. However insurance policies can differ greatly. Each company has its own criteria and some policies exclude breast reduction no matter what your symptoms are. The best thing to do is see a Board Certified Plastic Surgeon that specializes in breast reduction surgery. Your surgeon will know how to submit a pre-authorization request on your behalf. If you should get denied, ask for an appeal, I have gotten approval for many patients this way! Good luck.

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

Insurance covers breast reduction only if there is a functional problem caused by large breasts.

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Insurance is less likely to cover breast reduction this time passes. Most insurance companies need objective evidence that there is a functional problem created by the large breasts. They may under the circumstances cover the cost of the operation. Don't get your hopes up however.

Breast Reduction and Insurance Coverage?

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 Thank you for the question.
Based on your description, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations we perform. 
You will need to check with your insurance company directly to see whether your policy covers this operation. They will also be able to tell you whether you will have any direct responsibility/expenses if you choose to undergo this procedure.
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.
Also, when dealing with health insurance companies, prepare to be persistent!
 I hope this helps.

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.