Breast Reduction Size for Insurance to Cover Surgery?

I would like to have a breast reduction. I'm currently a 40DDD. In order for insurance to cover the procedure, what size would I need to go down to?

Doctor Answers 28

Breast Reduction

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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.

Orange County Plastic Surgeon
5.0 out of 5 stars 88 reviews

Breast Reduction and Insurance Coverage

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One of the great mysteries in medicine is "will my insurance company pay for my breast reduction?" Of course there's no reason that a company that is being paid premiums should hide this information. But they do. So here's what you will need to do. First, your insurance company must provide you with the weight needed to be removed from each breast. They all have their own numbers-anywhere from 500g per side to 875g. And your surgeon MUST remove no less than this.

Now the stuff they won't tell you. Since I review cases for insurance companies I'll tell you exactly what you need. 1. You must see your primary care doctor on AT LEAST 3 separate visits solely for the purpose of neck, shoulder and back pain, shoulder grooving etc related to the breasts. 2. You must document the various bra or bras you have used 3. You must undergo physical therapy for several months 4 Weight loss must be attempted and documented how. 5. The medications you use for the pain/discomfort must be documented 6. You must have a referral letter from your PMD to the plastic surgeon 7. A thorough exam and documentation from the plastic surgery must be included.

All of this must be documented. If the preauthorization letter denies the surgery then this documentation is necessary to plead your case.

Insurance coverage for breast reduction

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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

Jonathan Amspacher, MD
Kansas City Plastic Surgeon
5.0 out of 5 stars 14 reviews

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Insurance Coverage for Breast Reduction

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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!

Insurance Coverage

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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 Candidate seeking insurance coverage

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Each insurance company has different guidelines. Moreover, insurance requirements are different depending on state and insurance plan. The process to receive insurance reimbursement for the breast reduction procedure can be quite frustrating.

There are a series of questions that must be answered prior to beginning the insurance process.
1. Have you experienced persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:
Pain in upper back
Pain in neck
Pain in shoulders
Painful kyphosis documented by X-rays
Pain / discomfort / ulceration from bra straps cutting into shoulders;
2. Have you had a mammogram within the last year?
3. Have you tried any of the following therapies for 3 months or more?
Supportive devices (e.g., proper bra support, wide bra straps)
Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
Physical therapy / exercises / posturing maneuvers

4. Have you seen a physician for the symptoms you have experienced? When?

Your physician must also be able to document symptoms such as back and neck pain, headaches, also needs to ensure that the estimated reduction is consistent with the insurance company’s requirements for your BMI.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 56 reviews

Amount of Tissue to be Covered for Breast Reduction Surgery

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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.

Breast reduction size for insurance to cover surgery.

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Thanks for your question.  Insurance companies look at the overall size of the patient not the patients breasts when determining how much tissue must be removed.  In other words, if we use an example of patient 1 and patient 2 who both have 40 DDD breasts.  And say patient 1 weighs 100lbs and is 5 feet tall while patient 2 weighs 185lbs and is 5'8''.  Patient 1 would need far less tissue removed to satisfy insurance requirements than patient 2.  Insurance goes by body surface area which is a factor or weight and height, not breast size.  Hope this helps.

Shaun Parson, MD
Phoenix Plastic Surgeon
4.8 out of 5 stars 47 reviews

Breast Reduction Size for Insurance Coverage

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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

Breast Reduction - Insurance Coverage

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Each insurance company is different, and each has its own rules with respect to "coverage."  You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

It used to be that a 500 gram reduction on each side would be enough to obtain coverage; that is no longer the case and you cannot assume anything with respect to this.

You'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.

I hope that this helps and good luck,

Dr. E

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.