Breast Reduction Insurance Coverage

I am 37 years old from NJ, 5'3", weighing 140 lbs and wear a 36C. My breasts do not sag at all, yet. I have suffered from back problems for several years, but don't know if it is my breasts. I have always wanted to go to a B cup. Is there any possiblity that medicare would cover that? Also, does this type of breast reduction require the surgeon to remove and re-attach the nipple? Thank you.

Doctor Answers 17

In my opinion, medicare would not likely cover this small of a breast reduction

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I am from illinois and do not know if the Medicare administrator for your area is different than here. However, with most insurance companies you have the option of submitting a letter to predetermine your beneifts eligibility prior to surgery using photos, history, supporting letters, etc. This is not an option with Medicare. They will not respond to these types of letters in our area. Threrefore you have to undergo the surgery and submit the bills in order to determine if it is covered. Given the relatively small volume to be removed, it is my opinion that it would not likely be covered.

Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

You wouldn't qualify for a covered reduction

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First of all, you are too small to qualify for a reduction. Most all coverages require at least 500 grams of weight (about a full pound!) of tissue to be removed from each breast to be considered "medically necessary." You certainly don't have that much.

Secondly, it may be that your symptoms are from something else that a reduction wouldn't fix. Your doctor can check you for other causes of back pain.

Finally, if you have good shape and skin tone and don't need lifting, you could consider having some breast liposuction and reduce the size a little without any visible scars or need to move the nipple at all.

Significant Breast Reduction required for Insurance coverage

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Insurance Criteria for Breast Reduction Varies between Companies but going from a C to a B cup, I doubt any insurance policy would cover such a small amount being removed as it is unlikely to be the main source of your back pain. 
Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.
The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.
Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :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 though insurance criteria are becoming more and more restrictive.

Breast Reduction Surgery

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Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance.  In your case, it doesn't sound like insurance will cover the procedure because you are only reducing 1 cup size.  For each case, I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well).  Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the large breasts. Supporting documentation is usually very helpful.

Breast lift

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Medicare will not cover a very small breast reduction.The back pain might be related to other issues. A breast lift could be the best procedure for you. Best of luck!

Hisham Seify, MD, PhD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 19 reviews

Will not be covered.

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Thank you for your question!

Medicare would not cover this because in order for a reduction to be medically necessary, you would need to have a significant amount removed, about at least a pound to be exact. Usually, a size DD or larger. Also, it doesn't sound like you would even be a good candidate for a reduction. You may want to look into liposuction for the breast as that would be best for minimal removal of tissue. You should consult a board-certified plastic surgeon in order to get the best advice for you.

Many surgeons offer payment plans or financial assistance programs such as Care Credit. This may also be something you would want to look into providing that insurance will not cover the procedure.

As far your back problems, this may or may not be related to your breasts. I would see your primary doctor for this.

Best regards,

Dr. Speron

Sam Speron, MD
Chicago Plastic Surgeon

Breast reduction and insurance coverage

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As other doctors have stated, it is highly unlikely that an insurance company would cover the cost of your breast reduction. Depending on your geographic location, your body habitus, and your insurance company, your surgeon would likely be required to remove at least 400-500 grams of tissue. Starting as a C cup, that may make you smaller than a B cup when the operation is over, and it is very possible that the breast would have a flat, displeasing shape.

If you still wish to be smaller, a better bet for you would be liposuction, in which just fat is removed, or a breast lift (mastopexy), in which skin and fat is removed. During a mastopexy, with near certainty, your nipple and areola could be lifted without detaching them from the remaining breast tissue. These are cosmetic procedures, meaning that you will be responsible for all costs associated with surgery.

Hope this helps. Best of luck.

Insurance coverage of breast reduction operations

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In general, insurance companies cover operations that are done to improve your health (not your looks or body proportions.) In relation to breast reductions, the indications for coverage are typically related to neck or back pain from the weight of the breast, or sometimes rashes due to moisture under the breasts. It is not uncommon for the insurance company to want 500gms removed from each breast as coverage criteria (if this much is removed, they can expect some change in the back pain symptoms). Based on the numbers you listed, I do not believe you have anywhere close to this type of volume to remove (you would have no breasts left). You may benefit from a small reduction, but insurance will not cover it.

Small breast reductions

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To go from a "C" to a "B" it is extremely unlikely that your insurance company will pay for your reduction. Such a small reduction may not improve your back symptoms at all. If the breasts do not sag at all it is unlikely that you would need movement of the nipple areola complex.

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

Insurance does not pay for small breast reductions.

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I am afraid no insurance plan will pay for a breast reduction that only takes you down one cup size. Also, it is not likely that your back pain is due to your breasts if you are only a C cup.

The good news is that since you have no sagging, and you only want to go from a C cup to a B cup, you sound like an ideal candidate for liposuction only breast reduction. This procedure is essentially without scars, has an easy recovery, and also costs significantly less.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

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.