Breast Reduction Surgery-How to Get It Covered?

I am 5'2 and 130 pounds. My size right now is 36DD. I am looking to have a reduction due to aches in my lower back and neck area, but don't want to lose all of my breasts. How much would be required to be removed in order for my insurance to cover it?

Doctor Answers 9

Breast Reduction Surgery-How to Get It Covered?

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Based on your measurements you seem to need, and be a great candidate for a breast reduction. Getting breast reduction covered under insurance is very difficult. In fact getting them to tell you, as the consumer, the number of grams needed to get coverage will be nearly impossible. I suspect in the end it will have to be paid out of pocket.  The insurance frequently places the restrictions and makes it difficult without any medical substantiation. I have had many difficulties with my own patients (who truly needed it)  getting coverage. The best way to get coverage is to call your insurance company (my patient really raised a stink)...remember you are the consumer and you are asking insurance to cover a procedure that your doctor deems is medically necessary.

Breast reduction insurance coverage

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Typically you need to remove approximately 400 grams per breast to qualify for insurance coverage, but that number varies depending your your body size and your policy. Your best bet is to meet with a plastic surgeon who is an expert in breast reduction surgery to discuss your options.  Good luck.

David Stoker, MD
Los Angeles Plastic Surgeon
4.8 out of 5 stars 62 reviews

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

How to get Insurance Coverage for Breast Reduction

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Getting Insurance Coverage for Breast Reduction
Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company.  In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems..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.

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.

How to get approved for breast reduction surgery

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First of all, give your carrier a call and save yourself a lot of grief. Inquire specifically based on your dimensions how many grams would have to be removed. A DD is not very large, so your fear of having most of your breast removed, may be well founded. I understand cost can be a major limiting factor, but why would you let an insurance company dictate your breast size? Consider funding it yourself so that YOU will decide what size is best for YOU.

Breast size is not scientifically correlated with back/neck pain. Insurance companies have assigned 'magic' # grams removed will equal relief of symptoms. NOT true. They are arbitrary numbers, which if not met, makes insurance coverage null and void.

Weight transfer is the answer to symptom relief caused by heavy breasts. The Ultimate Breast Reduction successfully eliminates symptoms by transferring weight off of your skin  to your chest muscles. Breasts are reshaped and given a perky appearance. Upper pole fullness is achieved and breasts are permanently secured to minimize downward and outward displacement. There is no vertical scar, regardless of degree of ptosis or breast size. Breasts are custom designed to fit your frame.

Kind regards,

Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Breast Reduction and Insurance Coverage

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Each insurance company and plan has different requirements regarding coverage of breast reduction. Documentation and independent verification from your primary care physician, physical therapist, and/or chiropractor will help your case with the insurance company. Consult with 3 - 4 experienced and expert board certified plastic surgeons to understand your options.

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

Breast Reduction and Insurance Coverage?

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Based on your description you may be a good candidate for breast reduction surgery; It is one of the most patient pleasing operations we perform.

The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.  You will find that every insurance has its own specific “criteria” for the amount of breast tissue that must be removed; you will need to check with your insurance company for precise information.

Before undergoing the breast reduction procedure it will be very important to communicate your size goals with your surgeon.  Most patients wish to achieve a enough of a reduction to help with their symptoms while remaining proportionate with the remainder of their torso. 

With the goal of improving communication with my patients I find the use of photographs of “goal” pictures (and breasts that are too big or too small)  very helpful. I have found that the use of words such as “natural” or “C cup” etc means 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 be inaccurate.

Best wishes.

Breast reduction and insurance

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As for your specific situation it is always best to go for an evaluation first. Without an exam, it is impossible to say what volume could be reasonably removed to leave you a nice shape and volume.  

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

Breast reduction coverage

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Every insurer uses different standards so it is advisable to check on the carrier`s website. A board certified plastic surgeon who performs a lot of breast reductions should be knowledgeable, although the rules of the game are constantly changing. Many insurers require documented conservative medical management; in NY, they run the gamut of between 3 months to a full year of treatment.

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.