Breast Reduction 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

It sounds like you meet the criteria for breast reduction surgery. Contact your insurance company and see if it is a covered procedure under your policy. Some companies have it excluded no matter what your symptoms are. If it is a covered procedure, see a Board Certified Plastic Surgeon for a consultation. Your surgeons office will be able to submit to your insurance on your behalf to obtain pre-authorization. If the insurance company denies it, ask the office to file an appeal for you, many times the insurance company will reverse their decision. Good luck!

Every insurance plan has their own unique criteria on whether they will cover a breast reduction.  More and more, we are seeing plans where a breast reduction is not a covered benefit.  If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage.  Some set the amount in relation to your BMI (height and weight).  Others require extensive medical records documenting neck pain, back pain, and history of rashes.   The other alternative is to opt for a breast reduction as a self-pay option.   Start by visiting with a board certified plastic surgeon to learn more about your options.
Best wishes,

Dr. Basu
Houston, TX

Based on your description, it sounds as if you'd be a good candidate for a breast reduction.  Each insurance policy varies, so a call to your carrier can help you to determine if a breast reduction is a covered benefit.  A visit to a Board Certified Plastic Surgeon can help you to learn more about the procedure including risks and benefits. Your surgeon will also be able to assist you with the documentation to show that your condition is medically necessary.  Good luck!

Thank you for the question.

Based on your description you may be a good candidate for breast reduction surgery.
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.

Be persistent when dealing with health insurance companies;  keep in mind, that breast reduction surgery tends to be one of the most patient pleasing operations we perform.

 Best wishes.