Breast Reduction - Will Insurance Cover?

I am 5'3" weigh 155 and a size 34G. I have chronic back, neck & shoulder pain. I am unable to do several activities such as run, job, or workout on an eliptical. Is there any PS in the DFW area that would work with me to help get insurance to cover? Most I have talked to thus far do not seem to want to deal with insurance. :(

Doctor Answers 4

Will insurance cover your reduction?

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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

Breast Reduction for Symptomatic Hypermastia: Insurance requirements

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Breast reduction for the symptoms that you described should be able to be covered with most insurance policies. I would look for a plastic surgeon in your area who accepts most insurance plans, and has experience with breast reduction surgery. This is a common operation and usually for a patient with G cup breasts would qualify for insurance based procedure, but what an insurance company is looking for is failed conservative measures prior to a surgery. It would be helpful to gather this information prior to seeing a plastic surgeon, which may include documentation by your pcp or ob-gyn for failed attempts of treating neck and back pain with anti-inflamatories, treatment of rashes under the breast, and referrals for physical therapy and chiropractor treatments. This information, combined with medical photos, and an estimation of the amount of breast tissue to be removed should make a very good case for your breast reduction

Please let me know if you would like to come in for an evaluation for an insurance based breast reduction in Dallas or Frisco, TX.

Dr. Trussler

Andrew P. Trussler, MD
Austin Plastic Surgeon
4.9 out of 5 stars 52 reviews

Breast Reduction - Will Insurance Cover?

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Each policy is different but, in general, I would think that for the dimensions of your body you should be able obtain insurance coverage.  The companies typical use one or more formulas to decide what will be "covered," and, assuming you meet those criteria, they will pay for you to have that procedure.

However, and this is a big one, that doesn't mean that they'll pay what you want, or even what the surgeon wants.  Some surgeons participate in insurance company plans, in which case they are usually obligated to accept the payment and terms of whatever their arrangement is; others don't.  For surgeons who don't participate in your insurance company you have to find out what their fees are and whether you have out-of-network benefits which can be applied towards the surgeon's fee.

So that's part of the problem you're having.  You'll first need to find a surgeon in your network who you're comfortable with, and then go see him or her (or the other way around, of course) to find out how you can arrange to have this procedure done using your insurance.  Because of decreasing reimbursements it may not be that easy for you to find someone you like who will accept your insurance.

But that's what you need to do.

I hope that this helps and good luck,

Dr. E

Breast Reduction and Insurance Coverage?

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Thank you for the question.

Although I can only speak for the Southern California Area,  I think that if you continue to be persistent you will be able to find plastic surgeons who will be willing to help you undergo breast reduction surgery with insurance “coverage”.

You may also find that obtaining 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. Make sure you are consulting with  well-trained/experienced board-certified plastic surgeon.

Prepare to be persistent. Ultimately it will likely be worth it; breast reduction is one of the most patient pleasing operations we perform.

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.