I am confused. Are my conditions enough to warrant a breast reduction as medically necessary? With insurance cover it? (Photo)

Question

I am 29 years old. My bra size is 42 J. When I was 13 I wore a 32 D. I suffer every day with back and neck pain along with headaches and shoulder pain. My doctor told me and the insurance that I suffer from: torticollis, erythematous, back ache and macromastia. I currently have OHP. State medicaid from Oregon. Do you think they will cover the breast reduction and will the breast reduction help these issues that I have?

Scott C. Sattler, MD, FACS · Answer

OHP can be quite restrictive with coverage for procedures like breast reduction surgery. We typically write a pre-auth letter on behalf of patients that we feel are good candidates for breast reduction surgery and the insurance company gives a 'yes/no' answer. OHP has given us many 'no' answers.

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems you are experiencing secondary to breast hypertrophy; based on your description you may be an excellent candidate for breast reduction surgery at some point. It will be in your best interests, for several reasons, to achieve a lower/stable long-term weight prior to proceeding. “Official” recommendations of course would necessitate in-person consultation.
Breast reduction surgery is one of the most patient pleasing operations we perform. By removing “excess” breast tissue, adipose tissue, and breast skin  this operation reduces AND lifts the breasts to a higher position on the chest wall (in other words, the breasts are "automatically" lifted when a breast reduction is performed). By doing so, patients often find improvement in neck, back, and shoulder discomfort and find it easier to form their activities of daily living and exercise.
 Obtaining insurance coverage for breast reduction surgery will likely involve 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 letters/pictures from your plastic surgeon will help you obtain authorization.  Prepare to be persistent when dealing with health insurance companies.
When the time is right,  seek consultation with well-trained/experienced board-certified plastic surgeons. Ask to see lots of examples of their work and communicate your goals clearly.
I hope this, and the attached link, helps.  Best wishes as you work towards your goals.

Josef Hadeed, MD, FACS · Answer

Based on your photographs it appears that you could be an appropriate candidate for a breast reduction.  However, every insurance company differs with regards to the criteria that they utilize when determining whether to authorize a breast reduction.  You may want to contact your insurance carrier to see if your individual policy will cover a breast reduction.  Best wishes.

Ronald V. DeMars, MD (Retired) · Answer

You certainly have all the medical indications for a breast reduction and the likelihood it would dramatically reduce your symptoms is very high. However that does not mean it will be covered by insurance. As I understand it, OHP is for serious health issues related to disease and trauma, and I believe they specifically exclude breast reduction from their coverage. You can check with their patient advocate to get that information.

I am confused. Are my conditions enough to warrant a breast reduction as medically necessary? With insurance cover it? (Photo)

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