Will Affinity Health Insurance Pay for my Breast Reduction?

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

Based on your description you may be a good candidate for breast reduction surgery; it may be in your best interests to drop weight first.

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.

Good luck!

Each insurance company has its own criteria for whether or not a given procedure, such as a breast reduction, will be "covered."  At 5' 6" and 200 pounds, even with a bra size of 44DDD, my guess is that this will not be covered.  The company would be more likely to insist on weight loss or, at least, multiple documented attempts of conservative therapy, before agreeing to provide coverage.  That is just my guess, though.

The next issue, as always, is finding a board-certified plastic surgeon who participates in your insurance and/or is willing to accept what the insurance offers as "coverage" as payment for the surgery.  That has become increasingly challenging over the past few years.

The first step is to find a surgeon you're comfortable with and to try to obtain approval for the surgery.  I think it will be difficult based on what you say, but, as I indicated, each insurance policy has its own criteria.

I hope that this helps, and good luck,

Dr. E

H i,  I hope you find this article useful.  Good luck!

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.


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