Tips and Chances of Getting Breast Reduction Approved by Insurance?

Insurance companies generally look at two factors in deciding whether or not to cover a breast reduction surgery:  1.  Functional problems.  You mentioned several already - back/neck pain and shoulder grooving and pain from bra straps.  2.  The amount of tissue to be removed - a breast reduction and a breast lift are essentially the same operation.  The only real difference is in the amount of tissue removed.  Insurance companies use various charts to determine if the amount of tissue estimated to be removed is enough to meet their requirements. This is usually based on your Body Surface Area which can be determined by your height and weight.  I looked up your BSA and determined that you would need to have about 440-480 grams of tissue removed in order to be covered.  Some insurance companies demand more than that.  I'm not sure off the top of my head what Blue Cross/Blue Shield requires.  Some insurance companies throw other obstacles in your path such as a requirement that you be examined by a chiropractor to determine that your issues aren't related to skeletal problems, a three month trial of anti-inflammatory agents to see if that helps your pain, etc.  At any rate, your examining plastic surgeon can help determine whether or not you will qualify for insurance coverage.

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

Thank you for the question and congratulations on your decision to proceed with 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.
 This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.

Best wishes.