I'm 27 yrs old, 5'5, 170 lbs, and DD cup. Breast Reduction and Insurance?

27 y.o, 5,5/170/ 38 DD.My insurance BCBC approve my breast reduction BUT the surgeon should takes 500 gr from each side of my breast.surgeon has recommended 250 gr. BCBC use some ''calculator'' to see how many gr they can take off.I have back pain and the operation will be on med reason/my doctor said that I would not be proportional to the body if I have the size ''A''. What can my doctor do? write a letter to the insurance and explain that 250 gr is enough to pain in the back and be proportionate?

Doctor Answers 8

Breast Reduction through Insurance

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Thank you for your question.

Understandably, this is frustrating for you.  You have a few options.  Ask your plastic surgeons' office to help you appeal the "minimum amount of tissue removed" for authorization.  This may be a long process and it may or may not result in a different outcome.  You can visit with a few surgeons to see if they agree with the amount of tissue that needs to be removed and see if you are comfortable with that amount of tissue removal.

Your last option would be to NOT go through your insurance for this surgery -- but ideally, we know that you would like the insurance to take care of this.

Best wishes.

Breast reduction requires minimum amount tissue removal

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Thank you for your question.  Unfortunately, the scenario you outlined happens every day to women with large breasts.  Many insurance companies have miminum tissue removal amounts, such as 500 grams.  One option is to appeal the insurance companies decision.  You can formally file an appeal or your doctors office can do it for you.  Occasionally a patient or their representative can file an appeal and ask for a physician to review your case.  If you can provide supporting material that even a 250gram reduction will improve your symptoms, you may prevail.  In our office we have a full-time insurance "coordinator" to handle these issues as it can be difficult for the patient to navigate the insurance system by themselves.  Ask if your plastic surgeons office staff can assist you in this matter.  Keep in mind that your plastic surgeon's office staff will be more familiar with your insurance company in your state, and they may not take any additional steps because they know from experience that it is futile.  Hope this helps.

Tracy M. Pfeifer, MD, MS

Tracy Pfeifer, MD
Manhattan Plastic Surgeon
4.8 out of 5 stars 29 reviews

Breast Reduction and Insurance

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Great question, but the answer is not going to please you. You chose the BCBS health plan. So before you signed up the policy outlines the requirements in "that" plan to obtain health insurance coverage for breast reduction surgery. So we must assume the "minimal" amount of removal is 500 grams/side, that is approx. a pound per side. Yes you can always ask for an exception but in over 34 years of practice I have NEVER obtained one for lowering the required amount to be removed. In fact a removal of ONLY 250 gms. in my eyes classifies you as a lift/reduction not a reduction/lift. Please inform us of the outcome. 

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Will insurance cover my breast reduction?

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-Without examining you and/or seeing photos of your breasts, it is difficult of course to estimate how much tissue could be removed safely from each breast. However, it appears that your insurance company is requiring that a lot more breast tissue be removed than your plastic surgeon feels could be removed safely.  Each insurance company has its own strict criteria that need to be met in order for a breast reduction to be covered, so your surgeon will not be able to change their requirement of 500 grams.

-One option is to get a second opinion from another board-certified plastic surgeon and see if he/she agrees that only 250 grams of tissue could be removed.

-Another option would be to pay out of pocket for the operation.


Best of luck to you!

Breast reduction and insurance.

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breast reduction guidelines differ from company to company and it is very common to get denied based on weight of resection.

250 gr is kind of low for a DD starting cup size. please discuss this with your surgeon or obtain another opinion before you appeal.

Insurance coverage not always consistent or even appropriate for breast reduction

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Seeking insurance coverage for breast reduction can be a very confusing and frustrating thing, for both patients and plastic surgeons.  Insurance companies have different guidelines for whether or not they will pay, and although they may tentatively approve the surgery in advance, if the guidelines aren't met they may deny the claim. (They often deny the claim even when the guidelines are met, but that's another story and I don't want to get sidetracked on a rant about insurance companies!).  Some things to consider: 1) Let your surgeon do the best operation for you with the best cosmetic result possible - whether or not that means that enough breast tissue is removed to satisfy the insurance company.  You must be prepared to pay for the surgery out of pocket.  2) A 250 gram per side reduction will likely not get paid by any insurance company.  As large breasts go, that would be a small large breast.  3) No matter how big your breasts are, relief of back pain after breast reduction is never guaranteed. Men have back pain too, and it's never caused by large breasts.

Breast Reduction and Insurance?

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We see these issues all the time with insurance companies. Of course you can appeal the decision and your doctor can write another letter. It may even be a good idea to get a second surgical opinion regarding the weight to be removed. That 250 grams sounds pretty low for aomeone of your ht/wt and a DD. Unfortunately we see many patients a year for breast reduction that do not meet the artificial guidelines set by the insurance carriers. Those patients pay for the surgery as a cosmetic procedure.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 reviews

Breast reduction and minimum reduction

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Welcome to Obama Care!  Insurance companies are making it tougher and tougher to get breast reduction surgery covered. If you want a reduction and your insurance company will not cover it, then I suggest you pay out of pocket.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 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.