I Don't Know if my Insurance Would Cover a Breast Reduction, Should I Still Get a Consultation?

I'm 5 foot even & have lost 26 lbs in the last 2.5 yrs, & within 15 lbs of the "normal" weight range. Weight loss everywhere else but not in bust (38D to 34DDD bra). My boobs are heavy, grooves in shoulders, difficulty in running, & I catch myself slouching. I workout 5 days/week. Would like to run. Some days, I feel disgusted because of the weight and pain. I'm confident I'd qualify for a reduction but worried that insurance won't cover it. Any suggestions would be helpful.

Doctor Answers 9

Insurance will probably cover your breast reduction but you never know.

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There is no precise formula for insurance coverage for breast reduction. Some policies don't cover it all. You can call your broker to see what the limitations of coverage are.

Insurance coverage of breast reduction

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Insurance coverage for breast reduction has gotten even trickier over the last few years.  Many companies require that a certain amount be removed for the surgery to be covered.  In a situation like yours, you would need to have the consultation, submit it for pre-authorization to the insurance company with a plan to remove a certain amount of breast tissue.  The more you remove, the smaller you will end up, but the better the chance of approval of the procedure.  Therefore, you really need to start by deciding what final size you want, having the consult and deciding how much to remove to acheive your goal, and then submit and see what the insurance company comes back with.

Insurance for Breast Reduction

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You should defiantly go in for a consultation, it sounds like you are a great candidate for a breast reduction. Most plastic surgeons will not directly take insurance so you may have to pay out pocket. However, your surgeon will be able to send authorization and medical records to you insurance company stating the medical necessity for the procedure in which case your insurance company may reimburse you for the procedure cost.

John S. Poser, MD
Gainesville Plastic Surgeon
3.8 out of 5 stars 11 reviews

I Don't Know if my Insurance Would Cover a Breast Reduction, Should I Still Get a Consultation?

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You certainly sound like a good candidate for a breast reduction

Have your surgeon send in a prior authorization and records from your primary care physcian

Hilton Becker, MD
Boca Raton Plastic Surgeon
4.6 out of 5 stars 15 reviews

Breast Reduction and Insurance Coverage?

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Thank you for the question. Based on your description, you may be an excellent candidate for breast reduction surgery;  it is one of the most patient pleasing operations we perform.This operation is best done when you have achieved a long-term stable weight, if you are not there already.

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 are seeing a well-trained/experienced board-certified plastic surgeons.  Ask to see lots of examples of his work and communicate your goals clearly.
When dealing with health insurance companies, be prepared to be persistent.

Best wishes.

Need a consultation to determine medical necessity

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You're definitely on the right track. There is no way to know if insurance will cover your breast reduction until you come in for consultation, 

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Breast Reduction Covered by Insurance

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It is very possible that you may qualify for insurance coverage, but each insurance company has their own requirements, so you should have a consultation with a Board Certified Plastic Surgeon that specializes in breast surgery. Your surgeon is very familiar with the ins and outs of the insurance companies and will be able to help you get approval. Most insurance companies require that you need at least 500 grams of breast tissue removed from each breast and that equates to about a DD cup size. Some insurance companies require that you are within a certain range of your ideal weight, but this can be difficult when exercising is a challenge due to heavy breasts. Should you get turned down by your insurance company, ask your surgeon to appeal your case, I have succeeded getting many patients approved this way. Good Luck!!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 81 reviews

Insurance cover breast reduction

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I would recommend you start with a consultation. The worst that can happen is you find out more about the procedure, spend 30-60 minutes of your day to do so, and then get turned down. Chance are if you are as large as you say, you will find out about the procedure and get approved. Your back, shoulders, will thank you. 

Rick Rosen, MD
Norwalk Plastic Surgeon
4.8 out of 5 stars 28 reviews

Reduction covered by insurance

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Breast reduction is a covered benefit in many insurance plans, but may have varying qualifications from policy to policy.  A great place to start is with a phone call to your insurance carrier asking about the coverage and requirements.  A visit to a Board Certified Plastic Surgeon can help answer your questions about the surgery itself.  Insurance carriers generally require information from a surgeon and photos of the area to approve benefit coverage.

Mennen T. Gallas, MD
Katy Plastic Surgeon

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.