Is There a Chance my I.C Won't Cover a Reduction? I'm 5"7, 38 DDD with Rashes and Pain.

I dont have really severe grooves in my shoulder because I use shea butter and I wrap my straps up. However, I do have the back pain, rashes and grooves under my breasts, and I recently had fluid build up in my shoulder which led to severe pain in my arm. I know I fit the requirements but you never know with insurance companies.

Doctor Answers 9

Insurance coverage

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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.

Breast Reduction Candidate?

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Thank you for the question.

There is no doubt that your very large breasts may at least be contributing  symptoms you are suffering from.  Breast reduction surgery  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.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're saying a well-trained/experienced board-certified plastic surgeon.

I hope this helps.

Will insurance cover my Breast Reduction

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You hit the nail on the never know with insurance companies.  Some plans exclude breast reduction no matter what the patients' symptoms are.  While it sounds like you have many of the symptoms that should qualify you for insurance approval, you just never know.  I have been in practice for 12 years and still can not make heads or tails of why they approve some patients with minimal symptoms and deny others with gigantic breasts and deep shoulder strap grooves. 

The bottom line is that you need to see a reputable Plastic Surgeon whose office is willing to try hard to get you approved for an insurance breast reduction.  Hopefully, they will be successful with your assistance.  I always tell my patients that the insurance companies are more receptive to the patients then they are to us, so you may have to be the "squaeky wheel" to help move the process along. 

Laurence Weider, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 102 reviews

Breast reduction coverage

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Each insurance company has different criteria to approve breast reductions.  You have to check with yours and go from there.

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

Insurance coverage for breast reduction

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Not only are there differences between insurance companies as to what they will cover, but a single insurance company may offer different policies. So it will depend not only on your insurance company but your individual policy. Your board certified plastic surgeon should be able to get a prior authorization from your company as to whether your policy covers the procedure and if there are any criteria (for example how much tissue must be removed) for coverage. If they won't cover it, you can usually appeal their decision but may or may not get them to reverse their denial. Good luck.

Margaret Skiles, MD (retired)
Sacramento Plastic Surgeon

Insurance Coverage of Breast Reduction

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It sounds as if your breast reduction would be covered considering the information that you provided.  Most women with symptoms and 38DDD breasts would be covered.  There is a good bit of variation, however, and some policies contain an outright exclusion of coverage of this procedure.  Your best bet is to obtain a consultation with a BC plastic surgeon who can then communicate with your insurance carrier.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Is There a Chance my I.C Won't Cover a Reduction? I'm 5"7, 38 DDD with Rashes and Pain.

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With a well written letter of predetermination you should be able to achieve a covered approval. This is based upon your history, physical findings, photos, tests. 

Your surgeon should write a letter to ask them.

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There really is no way to know if your insurance will cover the procedure.  Your surgeon will make an estimate on how much tissue needs to be removed (in grams) and the insurance company has a criteria for weight and height to how much needs to be taken off.  If these numbers match, and you have some of the symptoms, you will get approved.  Good luck!

Breast Reduction - Is There a Chance my I.C Won't Cover a Reduction? I'm 5"7, 38 DDD with Rashes and Pain.

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Hi Daenyris,

Exactly right, you never know - so you have to find out.

Each insurance company is different and has its own requirements as to what will be a "covered" procedure (in quotes because the next issue is finding a surgeon you like who will accept what the insurance company says is adequate compensation as payment for the surgery).  There is typically a minimum reduction of about 500 grams (a little over a pound) from each side, but those standards should not necessarily be applied to all patients and, increasingly, they're not.  Instead, you have to look at the amount of excess breast tissue relative to the person's frame (ie, height, weight, etc).  Smaller amounts than that can receive approval from the insurance company, depending on many other factors including, as you indicate, rashes and associated symptoms.

The first step is to contact your insurance company and obtain a list of the surgeons who participate.  Alternatively, you can contact any surgeons you want to work with and make appointments to see them.  Either way, your surgeon will help you with precertificationi and any other requirements related to the insurance coverage.  You may need to submit photos and other documentation.  Once that's done and approval is obtained, you can go ahead and schedule the surgery.

All of this should, of course, be done in consultation with your plastic surgeon to make sure you're getting the best advice as you move forward.

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.