Am I a good candidate for insurance to cover a breast reduction? (Photo)

I am 5 foot and 99 pounds and about to be 21 years old unsure of the exact size of my breasts but ever since having a baby they are huge. I've been to the doctor for neck and back pain. I have trouble getting comfortable while sleeping and while exercising. It hurts to stand or walk for long periods of time. Hoping Someone can tell me if they think I'd qualify

Doctor Answers 5

Will insurance cover your BR?

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.

Breast reduction surgery: Will insurance pay?

If you breastfed your baby, you should wait at least six months from the time you stopped before you have a consultation so you know your true final size and shape. The usual process is then to have your plastic surgeon send your pictures to the insurance medical director or presurgical  evaluation team, along with a letter of the medical symptoms you are having from your large breasts. Health insurance companies often respond within a few weeks. Sometimes letters from your other health care providers help to corroborate the cause of your symptoms and validate your need for breast reduction surgery. These letters are especially useful if you need to request  a second review or appeal if you are initially denied. Hope this is reassuring. For more information on this and similar topics, I recommend a plastic surgery Q&A book like "The Scoop On Breasts: A Plastic Surgeon Busts the Myths." 

Ted Eisenberg, DO, FACOS
Philadelphia Plastic Surgeon
5.0 out of 5 stars 61 reviews

Breast reduction insurance coverage

Thank you for your question,  This is one that we frequently face during a breast reduction consultation.  Based on the information that you submitted, your BMI is 19.3 kg/m2.  Most insurers use the Schnur Sliding scale to determine the minimal amount of breast tissue required for removal.  Based on the Schnur scale, you will need 550 gm of tissue removed.  This may be the vast majority of your breast tissue by the picture that you included with your question.  Your first step is to call your insurer and determine if this is a covered benefit and exactly what their coverage criteria are.  Then seek the opinion and guidance of a board ceritifed plastic surgeon.  The functional improvement with breast reduction surgery can be immediate and life changing.  You need to make sure that the cosmetic outcome is in line with what you want to see in the mirror after the surgery.  Even a smaller reduction can have the desired physical benefit but leave you with the size and proportions that you desire, it just may not be covered.

Breast reduction and insurance

You need to first contact your insurance company and find out their criteria for approval, and then go for a consultation.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Breast Reduction and Insurance

It is possible that you are a candidate for breast reduction surgery, however, it will depend on your insurance company. Different insurance carriers have different requirements. You can call your insurance company to find out if it is a covered procedure under your policy and ask what you need to do to get pre-authorization, or you can see a Board Certified Plastic Surgeon who specializes in breast surgery to help you go through the process. It can be challenging, as insurance companies do have requirements, however, your surgeon would be able to help you! Good luck.

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 68 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.