Breast Reduction Insurance Coverage for Patients Below 18?

Question

I am 17 years old and I weigh 130 pounds. I am 5'3" and have a 38 F/G bust. I want to get a breast reduction but my insurance say "patients are generally female and at least the age of 18". Because I am a year below this, will it effect the approval of this surgery? I have chronic neck and back pain and have quite a difficult time doing everything because of my breasts. I really want the surgery done now, so do you think my insurance would cover it? What should I do to get covered, what doctors should I see? My health insurance is Boston Health Net Plan. Thanks!

Otto Joseph Placik, MD · Answer

Your best option is to seek the evaluation of a board certified plastic surgeon and have them prepare a letter of predetermination of benefits letter to your insurance carrier to ascertain coverage. This will best answer your question whcih in my opinion should be covered.

Scott C. Lindsay, DO · Answer

Thank you for your question.
You need to reach out to your insurance company for your answer. Find out if this is a covered benefit and what requirements need to be met. Schedule a consultation with a board certified plastic surgeon to discuss your options. Best wishes!

C. Bob Basu, MD, MPH, FACS · Answer

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

Raj S. Ambay, MD · Answer

Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier. Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front. Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days. The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.

Jeffrey Zwiren, MD · Answer

It is certainly possible that a teenager would be a candidate for a breast reduction. If the breast are excessively large and disproportionate to your body size and are causing neck back and shoulder pain. All insurance plans are different about qualifying for coverage.

Robert L. Kraft, MD, FACS · Answer

You are correct that insurance companies have recently set minimum ages for breast reduction.  Someone who, in all likelihood, has no understanding of female anatomy and development, has decided from on high that if a reduction is performed on a 17 year old, the breasts may continue to grow but that 18 is better.  I personally think that there is no such correlation but that, given that many 18 year olds go away to college, this is simply a way for them to save money.  What you should do in this next year, before you will become eligible to have the surgery, is to comply with every aspect of what the insurers call conservative medical management--ie, chiropractic, physical therapy, back x-rays, orthopedic or neurology consultation,  etc.  Document, document, document.  Find a plastic surgeon now with whom you are comfortable and whose office can research your insurers' particular requirements such that, the minute you turn 18, the preauthorizaton can be requested.  If your plastic surgeon performs a significant number of breast reductions, he or she will be knowledgeable on how to navigate the insurance system on your behalf.  Best of luck!

Tom J. Pousti, MD · Answer

The best way to obtain insurance coverage for breast reduction surgery involves some &ldquo;hoops&rdquo; 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 &ldquo;authorization&rdquo; for the procedure.

	This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're saying a well-trained/experienced board-certified plastic surgeon. Good luck!

Pat Pazmino, MD, FACS · Answer

Patients today have many great options in breast reduction surgery. Young patients should understand that their breasts will continue to grow and change at least until their early 20s. For this reason and to make sure that the patient understands the seriousness of the surgery, it is not recommended to perform a breast reduction surgery before the age of 18. Your best bet is to work with a board-certified plastic surgeon who has a great deal of experience in breast reduction and will be able to assess you and help determine what procedure will help you meet your needs and help you obtain a long-lasting results. Remember that you are quite young and the decisions that you make regarding surgery at this age you will live with for the rest of your life.

Peter A. Aldea, MD · Answer

It is truly impossible to answer your question because not only does every single insurance company have different approaches to "covering" Breast Reduction but each insurance company sells many DIFFERENT policies which may or may not have breast reduction benefits.
The best thing to do is check your policy's book and see if you have such benefits and which local plastic surgeons work with your insurance company. If you have not breast reduction benefits no amount of calling or arguing would help. If you do have coverage, research several plastic surgeons on your panel by checking them at www.PlasticSurgery.org and see one of them. Let him / her continue the approval process (PRECERTIFICATION) with your insurance company.
Good Luck.

Steven Wallach, MD · Answer

It sounds like you could benefit froma breast reduction. As long as you are of adult size and a menstruating regularly and are not still growing, I think it is OK to go ahead with the surgery. Your insurance company shoudl not hold your age against you if you have symptomatic macromastia (bra strap grooving, neck and back pain).

Breast Reduction Insurance Coverage for Patients Below 18?

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