Will Aetna Insurance Cover my Breast Reduction?

Question

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

Larry S. Nichter, MD, MS, FACS · Answer

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

David Stoker, MD · Answer

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.

Miguel Delgado, MD · Answer

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!

Craig S. Rock, MD, FACS · Answer

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.

Vincent N. Zubowicz, MD · Answer

Different companies and different policies have restrictions for breast reduction. A visit to the plastic surgeon's office will help clarify the situation.

Joshua Cooper, MD, FACS · Answer

-Definitely meet with a board certified plastic surgeon who can examine you carefully.  He or she will be able to better counsel you on the chances that insurance will cover your breast reduction.   Additionally, he or she may write a letter to your insurance company on your behalf to seek pre-authorization. 

	
		-Every insurance company has its own set of criteria that have to be met including: amount of tissue that should be removed based on your height and weight, documentation of symptoms, and sometimes they might require documentation that therapies such as physical therapy or massage therapy have failed to improve your symptoms. 
	
		-From your description, and based on your slender build along with large breasts, it sounds like you may be a very good candidate to undergo a breast reduction. 
	
		-Best of luck to you!

Sugene Kim, MD, FACS · Answer

Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Please check your insurance policy to see whether breast reduction is a covered procedure. Often times, insurance company will dictate how much breast tissue to be removed. Please visit an experiences, board-certified plastic surgeon to learn about the procedure, its cons and pros, benefits, and alternatives. Please contact your insurance carrier to learn about inclusion and exclusion criteria. Best wishes.

C. Bob Basu, MD, MPH, FACS · Answer

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

Mennen T. Gallas, MD · Answer

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.

Steven Wallach, MD · Answer

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.

Will Aetna Insurance Cover my Breast Reduction?

Answers (14)

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