Will Aetna Insurance Cover my Breast Reduction?

I'm 23 years old, 5'7, 140lbs. with 34DD-DDD breasts.I'm very active and enjoy sports. But, too much physical activity and my back aches and neck pains are unbearable. I constantly have rashes under my breast and on my shoulders. My insurance is Aetna, I was wondering if you know if they would cover a reduction. Thanks

Doctor Answers 15

Breast Reduction Insurance Criteria varies

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Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Insurance coverage

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Your policy is likely to cover your breast reduction surgery, but Aetna has many different policies so coverage varies greatly.  See your surgeon to discuss your best options.

David Stoker, MD
Los Angeles Plastic Surgeon
4.8 out of 5 stars 62 reviews

Will Aetna cover your breast reduction?

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Aetna is the best person to answer this question.  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 benefits for breast reduction

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This benefit varies from carrier to carrier and policy to policy.  I would recommend a phone call to your insurance company to inquire if a breast reduction is a covered benefit and the criteria required for approval.  A vist to a Board Certified plastic surgeon is recommended for an evaluation.  A letter from a physician is often required for approval. Good luck.

Mennen T. Gallas, MD
Katy Plastic Surgeon

Will Aetna Insurance Cover my Breast Reduction?

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Thank you for your question and the detailed information you have provided.  There are many different policies with Aetna or any other insurance company.  By most standards you qualify, but your plastic surgeon's office has to obtain insurance verification and pre-determination for you and then they will be able to tell you what kind of coverage you have and what your portion will be.  Just make certain that you are being treated by an experienced plastic surgeon certified by the American Board of Plastic Surgery, there is no higher authority in plastic surgery.  Best of luck.

Ruben B. Abrams, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 19 reviews

Insurance and breast reduction

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Every insurance company is a bit different in terms of coverage for breast reduction. It is best for you to contact them and ask their requirements. Based upon what you wrote it sounds like you could be a good candidate.

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

Insurance company approval for a breast reduction

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You can call your insurance company and ask to speak with a claims representative. Ask them what are the specific requirements for coverage for a breast reduction.  The next step is to see a skilled, experienced plastic surgeon in consultation and at that time it can be determined if you are a candidate for the procedure.  Then a letter can be sent to your insurance company requesting prior approval. This whole process can take several weeks to complete.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Breast Reduction Covered by Insurance

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It is very possible you are a candidate for surgery, but all insurance companies have their own requirements, and each company has different policies where some have specific exclusions. You could call your insurance company and ask if your policy covers the surgery or see a Board Certified Plastic Surgeon who is well versed in all the ins and outs of obtaining pre-authorization. Good luck!

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

Will Aetna Insurance Cover my Breast Reduction?

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Almost all insurance companies will tell you they cover breast reduction. They just will not tell you what restrictions they place on the procedure. The only way to get that answer is to see a surgeon and have his office try and 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 - Aetna

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Based upon your description, it sounds like you would be an excellent candidate for breast reduction.  Aetna has specific criteria that need to be met to obtain insurance coverage, based upon your symptoms (back pain, rashes, etc.), how long you have had them, failure of non-surgical treatment and the amount of breast tissue to be removed (based upon your current size and surgical goal).  Aetna's clinical policy bulletin, which explains their exact requirements, is available on their website.  Go to Aetna.com and search for "clinical policy bulletin breast reduction".

I would recommend consultations with board-certified plastic surgeons experienced in breast reduction, who can review the procedure with you including the potential risks and benefits, as well as help you with the process of trying to obtain insurance coverage. 

Good luck.

Craig S. Rock, MD
Houston Plastic Surgeon
5.0 out of 5 stars 29 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.