What are my chances of approval for breast reduction?

Question

I’m 5’4” and 270lbs. My size is triple Ds. I’m currenly seeing a rheumatologist and an breast surgeon for chronic granulomatous mastitis. I’ve been to hospitals and my primary doctor for back, neck and shoulder pain. When I asked for a reduction I was told I had fibromyalgia and that a breast reduction is not an option. Now I’m seeing a plastic surgeon for a breast reduction. I’m afraid it won’t get approved. What are my chances it will? I have Anthem blue cross.

Randal Haworth, MD, FACS · Answer

With today's insurance plans under the ACA, less and less insurance companies cover breast reduction surgery despite if you may have symptoms such as painful bra strap grooving, neck, shoulder and back pain overly large breasts. However, I suggest contacting your insurance company and asking exactly what is and isn't covered in regards to treating macromastia with a breast reduction. If  they do offer coverage then ask for a list of in network providers whom you can then contact to set up an appointment and consultation with to address your concerns.

Ronald J. Edelson, MD · Answer

The world of insurance paying for breast reduction has changed considerably in the last few years.  Some insurance carriers state they do not cover breast reduction in any situation.  Also your bsurance company may feel you need to lose weight before they will consider it.  You should speak to your insurance company and find out what their policy if regarding breast reduction.  Good luck!

Kenneth Hughes, MD · Answer

None of us can predict what decisions insurance companies will make regarding coverage for BR surgery or what documentation will sway their decision. BRs which are medically necessary (i.e. you suffer back, shoulder, and neck "pain" with DOCUMENTED medical attention over a period of a YEAR) are typically covered by most medical insurance providers.  If not, they may try to deny you based upon a lot of things such as lack of symptoms, lack of previous medical management, and lack of enough tissue that should be removed. 
Read your Anthem Blue Cross medical insurance certificate of coverage. Determine what medical information is required for Anthem Blue Cross to issue a pre-authorization or predetermination of benefits for BR surgery. Then seek consultation with a board certified plastic surgeon who can evaluate your medical condition and history, discuss the pros and cons of this surgery as it applies to you, determine the amount of tissue to be removed, and help you in completing the paperwork required.  
Kenneth Hughes, MD, Board Certified Plastic Surgeon
Los Angeles, CA

Jonathan Amspacher, MD · Answer

You will find that coverage of the procedure varies widely from one insurance policy to the next. Many insurance companies will cover if you have 500 grams of excess breast tissue (about 1 lb) per side and rarely some may cover as low as 350 grams. However some companies may require a kilo or more depending on your height and weight.  
.  You will have the least problems if you are in good health and a nonsmoker.  I don't perform breast reduction until a patient has quit smoking for 6 weeks before surgery because smoking greatly increases the odds of complications with surgery.  I also require that patients get their BMI down to 35 and have their diabetes under good control because we have done studies that show this decreases the risk of complications with surgery or anesthesia.  
This being said, before you go forward with surgical procedures you may want to see your primary care physician to see if they have any other recommendations and such as therapy or medications. Many neck and back pain symptoms can be treated very successfully with strengthening of the spinal supporting musculature and this may be required by your insurance company.  This requires some time and effort but may provide a lifetime of benefit.   
Insurance companies frequently want to see a record of having been treated by nonsurgical methods for at least six months and not getting improvement with conservative treatments.  This usually means that you have tried diet and exercise, medications and possibly therapy or chiropractic and have not gotten adequate relief.  The next thing to do is get an exam with a board certified plastic surgeon with a good reputation. He should be able to perform an exam to tell exactly how much excess breast tissue you have.  Then the surgeon will write a letter to the insurance company and see if they will give approval for the surgery. The insurance company will send both you and your provider a letter with their decision within a few weeks in most cases.  Many patients are able to get insurance coverage for the procedure, but if you do not qualify many places offer a significant reduction in the price for out of pocket cases that are paid in advance.  Best of luck on your journey

Gary M. Horndeski, MD · Answer

At
5’4 and 270 lbs, your BMI is 46, which puts you at a high risk for surgery complications.  An alternative to consider is liposuction of
the breasts.  Your insurance company may
or may not authorize this procedure.Best Wishes,Gary Horndeski, M.D.

Ricardo Vega, MD · Answer

Hello, thank you for your inquiry. It would be best to seek an in person consultation and examination with board certified plastic surgeon to discuss all detailed information. Best of luck!

Urmen Desai, MD, MPH, FACS · Answer

It is always difficult to predict.    I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

Ryan Neinstein, MD, FRCSC · Answer

Thanks for the question, when the symptoms and anatomy line up as they do in your case the carriers usually are pretty good about approving the operation.Maybe you need a letter of support from a chiropractor or physiatrist to prove the symptoms are related to breast size and they are not improved with non surgical treatments

Daniel Barrett, MD · Answer

Dear smhernandez18,as long as you meed requirements, there is a chance that your surgery will be approved. If you are considering a surgery, I would suggest you to consult a board-certified plastic surgeon. Only after a thorough examination you will get more information and recommendations.Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Liana M. Lugo, MD · Answer

Hi! Thank you for your question. Some insurance companies do not cover breast reductions at all, but most do. What they want is for you to prove it is “medically necessary.” To show this, they require a certain weight of tissue removed. Insurance companies often use the Schnur scale to determine quantity of breast tissue removed during surgery. The scale is based on height and weight. Therefore if your BMI is high, the surgeon will have to remove a lot of breast tissue in order for the insurance to cover it. I have had some patients where the amount “required” by insurance for me to remove would be equivalent to removing the entire breast. We can’t safely do that, so insurance will not cover. In those cases, we quote them for a cosmetic reduction and they decide how much tissue is removed. Seek an evaluation with a board certified plastic surgeon. I hope this helps and best of luck!

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