How to Convince Insurance to Cover Breast Reduction?

Question

I am 20 years old and I have 38DD breasts. I would love to get a breast reduction because as long as I can remember I have had back, neck and knee problems. I have horrible posture and running and  exercising is difficult because my breasts get in the way. I can't afford it myself so I was wondering how to prove to your insurance that my large breasts are causing my pain? Thank you for your time.

Farbod Esmailian, MD · Answer

They look as several factors when they try to decide if the patient will be covered under the health insurance coverage for breast reduction.  They look at your symptoms in addition to your height and weight, breast size and the amount to be removed.  They have a formula that is based on your height and weight and that will determine how much they will want to have removed in order to cover the surgery.
I have had good success getting breast reduction covered by the patient health insurance benefits. 
Good luck.

Jonathan Amspacher, MD · Answer

You will find that coverage of the procedure varies widely from one insurance policy to the next. Many insurance companies will cover if you have 500 grams of excess breast tissue (about 1 lb) per side and rarely some may cover as low as 350 grams. However some companies may require a kilo or more depending on your height and weight.  This being said, before you go forward with surgical procedures you may want to see your primary care physician to see if they have any other recommendations and such as therapy or medications. Many neck and back pain symptoms can be treated very successfully with strengthening of the spinal supporting musculature and this may be required by your insurance company.  This requires some time and effort but may provide a lifetime of benefit.  
  
Insurance companies frequently want to see a record of having been treated by nonsurgical methods for at least six months and not getting improvement with conservative treatments.  This usually means that you have tried diet and exercise, medications and possibly therapy or chiropractic and have not gotten adequate relief.  The next thing to do is get an exam with a board certified plastic surgeon with a good reputation. He should be able to perform an exam to tell exactly how much excess breast tissue you have.  Then the surgeon will write a letter to the insurance company and see if they will give approval for the surgery. The insurance company will send both you and your provider a letter with their decision within a few weeks in most cases.  Many patients are able to get insurance coverage for the procedure, but if you do not qualify many places offer a significant reduction in the price for out of pocket cases that are paid in advance.  Best of luck on your journey

Larry S. Nichter, MD, MS, FACS · Answer

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. Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria.
	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.

Sam Jejurikar, MD · Answer

If you have documented symptoms of back pain, neck pain, shoulder pain, severe grooving from your bra straps, or rashes, your insurance carrier may cover a reduction mammaplasty. Before you start the process, you should check with your insurance carrier to ensure that you don't have a policy which excludes coverage for for breast reduction and to see if your insurance company requires a regimen of physical therapy prior to covering the procedure.  Your insurance carrier may also mandate that your body mass index be below a certain number prior to authorizing surgery.
Once that has been clarified, your first step is consultation with a board certified plastic surgeon.  He or she will evaluate whether you are a good candidate for surgery. Depending on your Body Mass Index, you may need to lose weight prior to surgery to lessen the risks of surgery, improve the aesthetic outcome, and to satisfy criteria from your insurance company.  Your plastic surgeon will need to submit photos to your insurance carrier and will likely need to submit a letter documenting the amount of breast tissue he or she anticipates removing and documenting your symptoms.
Even with all of that, sometimes insurance carriers are slow to approve the surgery.  It is  definitely worth pursuing, though, particularly given the symptoms you desribe.
Hope this helps.  Best of luck.

Scott C. Lindsay, DO · Answer

Hello and thank you for your question.
It is not a matter of convincing your Insurance company, but meeting the requirements to have it approved. Schedule a consultation with a board certified plastic surgeon to discuss your options. The office will help you through the insurance process. Best wishes!

David Finkle, MD · Answer

Some, not all, health insurance companies will cover the cost of a breast reduction procedure.  To qualify you will have to meet all the requirements set forth in their policy, which vary widely from company to company.

	The insurance companies will need to have a pre authorization letter sent to them by the surgeon which describe the reasons for requesting the procedure.  A minimum amount of tissue will need to be removed at the time of surgery based on your body mass index, a photograph documented the deformity will be needed, symptoms relating to the breast weight will need to be documented.  Some carriers will even require 6-9 months of "conservative therapy" for the neck, shoulder and back pain with PT/OT therapy, anti-inflammatory medication usage and supportive bras (who ever heard of a non supportive bra!).  Basically, they are looking for any excuse to not cover the procedure, it may take multiple letters and appeals to determine coverage.

	Good Luck!

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

Sugene Kim, MD, FACS · Answer

Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage. Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed. If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay. Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee. There is a geographic difference as well. It will vary from $8000-$10,000. Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits. Good luck to you.

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.

Fredrick A. Valauri, MD · Answer

Insurance coverage for breast reduction surgery varies from company to company and requires that you meet certain criteria.

	These include documentation of neck and back pain, documentation of physical therapy for the neck and back pain, an insurance-specified anticipated minimum  amount of breast tissue removal,  and photographs.

	This information will need to be submitted to the insurance company by the plastic surgeon's office for authorization to cover the breast reduction surgery.

How to Convince Insurance to Cover Breast Reduction?

Answers (17)

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