24 yo, 5'7" and 175lbs, size 36DDD breasts, hoping for United Healthcare to cover a Breast Reduction Surgery - Good Candidate?

I have been interested in breast reduction since I was 15yo. I am considered "normal" weight for my height (slightly on the upper range), & have had large breasts ever since I hit puberty. Even when I had lost weight and was 130lbs, I was still a large 34DD. They very dense and heavy, so I have been experiencing non-stop back, neck, and shoulder pain. My breasts hurt when I run or jog. I do NOT plan to have children.

Doctor Answers 4

Breast reduction surgery coverage

When it comes to breast reduction surgery, insurance companies tend to look at two criteria - the amount of tissue to be removed and functional problems associated with the large breasts.  You have already noted some of the functional problems that you have been having.  Each insurance company has criteria based on height, weight, and body surface area by which they determine the amount of breast tissue that needs to be removed in order to have coverage.  I would suggest that you visit a board-certified plastic surgeon who can examine you in person and review your options with you.

Atlanta Plastic Surgeon
4.8 out of 5 stars 24 reviews

Breast Reduction covered by insurance?

Under certain circumstances Breast Reduction is covered by insurance. 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

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 154 reviews

Breast Reduction Surgery - Good Candidate?

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. Of course, definitive assessment and advice would require in person evaluation.

“Typical” patients who present for breast reduction surgery are women who have disproportionately large breasts, causing problems such as neck/back/shoulder discomfort, postural changes, bra strap grooving, skin irritation/rashes under the breasts, and/or difficulty with activities of daily living and/or exercise etc. There may be both physical as well as psychosocial “stress” caused by the disproportionately large breasts. Reducing breast tissue mass and elevating the breasts on the chest wall tend to improve or alleviate many of the symptoms associated with the disproportionately large breasts.

Patients considering breast reduction surgery should also consider the potential downsides (risks/complications) associated with the procedure as well. Poor scarring, for example may be associated with the procedure. Additional surgery may be necessary in the short or longer term for a multitude of reasons.
Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. 

When the time is right, I suggest that you seek consultation with well experienced plastic surgeons who can demonstrate significant experience achieving the types of outcomes you would be pleased with. Ultimately, careful selection of your plastic surgeon will be the most important decision you make. To this end, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery. Ask to see lots of examples of their work and preferably speak/see patients who have had similar procedures done.   I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps. Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,486 reviews

?good candidate for a breast reduction

I can't answer accurately without a picture but I can tell you that the requirements to get insurance to cover a breast reduction are some office visits from your primary care showing that you have some problem (such as back pain) from your breasts and you have tried other methods (advil, physical therapy) to make the back pain go away before resorting to surgery. You also need to have a certain weight of tissue removed from your breasts that is proportionate to your body surface area. For you that would be around 1 1/2 lbs per breast. The surest way to know is to have a consult with a board certified plastic surgeon in your area. Good luck.

Karen Quigley, MD
Memphis Plastic Surgeon
4.8 out of 5 stars 27 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.