Breast Reduction: Insurance Issue?

My insurance requires me to go through their clinical policy bulletin with my doctor in order to review my case and determine eligibility for an insurance claim prior to the procedure. Do I need to do this with a PS or can I do this with my local PCP? Part of the problem is I have not yet met my PS so I do not know how much he would remove, but I want to go from a 34H to a 34C/D. Not sure how much that would be in grams and whether it would be enough for me to be able to claim this with my insurance.

Doctor Answers 5

Breast Reduction: Insurance Issue?

Even though the weight of breast tissue removed during a breast reduction varies with the density of the breast, but at any rate going from a 34 H to a 34 C/D usually means a significant amount of breast tissue, usually in the range of 1200 grams each side.  Now your height and weight is usually taken into consideration in determining whether you are eligible for insurance coverage.  In addition, insurance companies mostly now require you to meet other criteria, such as gait-training, a period of conservative management (and I am still trying to figure out what exactly conservative management for breast hypertrophy is!), physical therapy, etc.  So, yes you need to discuss your situation with an experienced plastic surgeon certified by the American Board of Plastic Surgery and he/she can guide you in the right direction.

Beverly Hills Plastic Surgeon
5.0 out of 5 stars 19 reviews

Call your broker to sort out insurance issues about breast reduction.

The best way to determine the course to seek coverage for breast reduction is to call your broker and see if the operation is covered and under what conditions.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.7 out of 5 stars 35 reviews

Meeting insurance requirements for a breast reduction

Every insurance company has different hoops to make you jump through.  Only a plastic surgeon is going to be able to give you an estimate of the amount of tissue to be removed.  This is out of the normal scope of practice for the average PCP.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 19 reviews

Breast Reduction: Insurance Issue?

Each insurance plan has different requirements but it is normally the doctor providing the service (the plastic surgeon) who initiates the process since they can give the best assessment of your need for a breast reduction.

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
4.9 out of 5 stars 68 reviews

Breast Reduction and Insurance Company Concerns?

Every insurance company will have different “hoops”  for patients to jump through. For accurate  information in regards to what type of physician you need to see initially,  you will be best served contacting the insurance company directly. Online consultants  will not be able provide you with this information.

Before undergoing the breast reduction procedure it will be very important to communicate your size goals with your surgeon.  In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup”   etc mean different things to different people and therefore prove unhelpful.
 Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also vary. 

Many of my patients choose to have enough breast tissue removed to help alleviate symptoms while retaining enough breast tissue to remain proportionate to the remainder of  bare torso.  

Once you have communicated your goals with your plastic surgeon, he/she will be able to give you an estimate as to how much breast tissue will need to be removed during the procedure.

 Best wishes;  when dealing with insurance companies prepare to the persistent.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 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.