Breast Reduction Size for Insurance to Cover Surgery?

It is no longer determined by the 500 gram rule. It all depends on your height and weight which is plugged into a equation which gives BSA (body surface area). This gives a number which determines how much breast tissue is required to be removed for insurance to cover it. It depends now on your height and weight. The heavier your are, the more breast tissue they want removed in order for the surgery to be covered.
What will happen at your doctors office is that photos will be taken and your surgeon will submit all this information along with the symptoms you are having to the insurance company, which will them determine if it is medically necessary.
Good luck.

Thank you for your question.  This is a very common and tricky question in that every insurance company has set forth their own specific parameters that must be met to deem a procedure 'medically necessary.'  In the case of breast reduction coverage, most insurance companies (but not all) require that a minimum of 500g of breast tissue be removed from each side.  They generally also require a long documented history of neck, shoulder, and/or back pain, and numerous letters and office note documentation from primary care physicians, chiropractors, orthopedists, dermatologists, and physical therapists attesting to the extent of physical hindrance of a patients large breasts and all failed methods of control (different bra's, physical therapy, medication use for rashes in the inframammary fold, etc...).  This is a lengthy process that typically requires an authorization process (and often an appeals process), but unfortunately most of the process is outside the control of the plastic surgeon.  If you are interested in having a breast reduction procedure and you believe as though you have a substantial case to warrant medical coverage, the first step is to call your insurance to see what their conditions for determining medical necessity are.  Then you should consult with a board-certified plastic surgeon who is well-experienced with breast reduction procedures.  Photos will be taken along with a thorough history documenting your symptoms and a claim can be made to your insurance company.  I hope you find this helpful and best of luck!

Hello and thank you for your question.
Every insurance company is different. Reach out to your carrier and find out what your benefits are and the criteria needed for breast reduction surgery to be covered. Schedule a consultation with a board certified plastic surgeon to discuss your options. Best wishes!

Insurance coverage of breast reduction is contingent on establishing a case for medical necessity. Patients will typically have documented evidence of neck/back and shoulder pain as well as rashes and bra strap grooving attributable to the increased breast weight. They will often demonstrate that these symptoms have been resistant to more conservative measures like therapy, weight loss and pharmacologic intervention.The requirements for reduction will vary from one insurance provider to the next. This may be a standard "500 gm per side" stipulation or a more customizable standard based upon body surface area/Schnur scale.As always, discuss your concerns with a board certified plastic surgeon (ABPS).

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

It all depends on your insurance provider and your measurements, specifically weight and height. Based on that information, your provider will then tell you how much of a reduction is necessary. 

The vast majority of insurance carriers require prior authorization for breast reduction surgery.  Multiple criteria must be met before authorization can be granted.
One of the more important insurance criteria for approval is the anticipated amount of breast tissue to be removed.  This number varies from insurance carrier to insurance carrier.  Many insurance companies use weight and height calculations to determine how much tissue should be removed from each breast.
In most cases, estimating the amount of breast tissue to be removed is relatively straight forward.  In borderline cases it can be very difficult.  Under these circumstances it may be impossible to meet the insurance carrier’s specimen weight criteria and still meet the patient’s aesthetic goals.  In this situation, the patient may have to answer a difficult question before proceeding with surgery regarding which issue is more important to them.
Even when these choices need to be made, the vast majority of patients are extremely happy with the size of their breasts following breast reduction surgery because their primary goal is resolution of their symptoms.  If you’re considering breast reduction surgery, consultation with a board certified plastic surgeon with experience in this area will be helpful.  An appropriate estimate of the amount of breast tissue to be removed should be easily accomplished.

Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria. 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. For you that would most likely reduce you to a large C to a large D cup size.. 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

In order for breast reductions to be covered by insurance, several criteria need to be met. Patients must have a documented history of symptoms such as neck/back pain and show some type of treatment for this-pain medication, physical therapy, accupunctur, etc. Also, the insurance companies will require photographs of the patient and a medical letter of necessity written by the plastic surgeon. The insurance companies also need to see about 500 gms of tissue removed from each breast in order for them to cover the procedure and deem it "reconstructive" and not "cosmetic".
If you are a DDD cup size now, you'd likely need to be downsized to a D in order for your procedure to be covered under insurance. Each insurance policy varies greatly and you should consult with a board certified plastic surgeon prior to planning this procedure.

Most insurance companies require around 500gms per side for approval. That is not an absolute amount but I have had no trouble getting the go ahead from providers when this estimate is made. Judging from your remarks, you might be as large as a "D" cup if only this amount were removed. Most women in my practice want to end up as a "C" cup, but not always.
In your case, an estimate of at least 500 gms per side would be placed on the insurance pre-approval forms along with various measurements of the body and a photograph of the problem. I doubt there would be any problem obtaining insurance payment for you operation.