Need a Breast Reduction, Not Sure if Insurance Will Cover?

I have a 14 inch difference between bust and band size, about a 34N or so. Severe and frequent upper back, neck, and shoulder pain, with headaches. I was diagnosed with T4 Syndrome a short time ago and it is recommended I undergo breast reduction to have full function returned. I have Premera insurance but was denied in March before I knew about my condition. Will this change anything? Will I /have/ to go through physical therapy before they approve? Thank you for your help.

Doctor Answers 6

More Symptoms = More Likely Insurance Coverage for Breast Reduction

Sounds like you are a great candidate for Breast Reduction due to the number of functional symptons you have from overly large breasts . Unfortunately, each insurance company has their own criteria. 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 through insurance criteria are becoming more and more restrictive.

Orange County Plastic Surgeon
4.9 out of 5 stars 154 reviews

Breast reduction

Most insurance companies base the decision of whether to cover breast reduction on a number of factors.  These include symptoms, photos your surgeon submits, and an estimate of how much breast tissue would be removed from each breast.  Without seeing photos, it is hard to tell you if you are a candidate.  t is becoming more and more difficult getting insurance companies to pay for breast reduction surgery.  You should check with your insurance company to find out what their policy entails.  Assuming you are an appropriate candidate for the surgery,  most of the time it just takes persistence  on your part to get them to agree to cover the surgery.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 27 reviews

Breast reduction and insurance

Thank you for your question.  Your insurance policy has certain parameters.  First, call your insurance company and find out if breast reduction is a covered benefit by your specific policy.  It is a covered benefit, then you have to try and get your reduction covered.  Since you were already denied, if it is a covered benefit, then you can appeal the decision.  You would tell the insurance company that you want to appeal their denial and your case should be passed along to a higher level.   In our office we have a fulltime insurance coordinators to help patients navigate the maze of the insurance company.  Ask your plastic surgeon's office staff if they can help you with this.  Sometimes it is a matter of persistence.  Hope this helps.

Tracy Pfeifer, MD, MS

Tracy Pfeifer, MD
Manhattan Plastic Surgeon
4.8 out of 5 stars 27 reviews

Each insurance company has their own requirements


Thank you for the question.  Each insurance company has their own requirements for breast reduction approval.  I would go on your insurance companies website or contact them to get a list of those requirements.  You and your plastic surgeon can then evaluate those requirements and see what documentation they need for approval.  It certainly sound like you are a candidate for a breast reduction.

All the best,

Dr Remus Repta

Remus Repta, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 162 reviews

Need a Breast Reduction, Not Sure if Insurance Will Cover?

The only way to know is see a surgeon, have him document your problems including a letter from any other health care giver supporting your need for a reduction and see what the insurance company says. Many of them will require you to go through physical therapy and/or chiropractic treatment with documentation that the treatment did not help you. It rarely makes a difference in symptoms but it allows the insurance company to hold on to their money longer and that is how they make their money.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 27 reviews

Breast Reduction and Insurance Covers?

Thank you for the question.

 Based on the description, you may be an excellent candidate for breast reduction surgery. Unfortunately,  online consultants will not be able to address your specific insurance coverage question. You will be best off checking with your insurance company and provide them with any additional medical information that you have.

 Generally speaking, 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.

This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.

When dealing with health insurance companies, prepare to be persistent. During this process it may help you to remember that breast reduction surgery tends to be one of the most patient pleasing operations performed.

 Best wishes.

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.