How to get insurance to cover a reduction?

Question

I’m about 5’2 and 130 lbs, and I have a 34H chest that I’m looking to size down to a C or D cup. I’ve had chronic back, shoulder, neck, and chest pain for years, and physical therapy hasn’t been much help. There’s also bruising and rashes that have been under my chest for a while now. I’m not totally sure if my insurance will cover a reduction, and I’d like to know how to get them to cover it.

James N. Romanelli, MD, FACS · Answer

Dear Hummingbird472

An H cup is too much for most women to carry!  It sounds as though you meet medical criteria for breast reduction.

The open question is exactly what benefits your insurance company provides.  Most plans cover breast reductions as medically necessary and in our practice about 80% of our patients can get this coverage.  A few plans, unfairly, exclude breast reduction surgery at any size.

We offer virtual consultations.   Consult with a board certified plastic surgeon to explore this further.

Best of Luck
Dr. Romanelli

Caner Kacmaz, MD · Answer

Health insurance does not cover cosmetic breast reduction, but plans usually cover breast reduction surgery that is medically necessary. In your case, you might actually be eligible in your own country. Insurance companies tend to not cover surgeries overseas.

Daniel Careaga, MD · Answer

In the absence of pictures but based on your description, it definitely sounds like you would be covered by your insurance. Different insurance companies will have different requirements but the average that most companies require to remove to qualify is approximately 500g. If you truly have an H cup bra there should be no issue getting well above that amount.

Edward Daniele, MD · Answer

Generally, everything you have mentioned is important symptoms for insurance to cover it. Insurance wants to see that you have bra strap grooving, back and shoulder pain, and have attempted therapy with no improvement. Given your size and symptoms you should not have an issue getting a functional breast reduction approved.

Azita Madjidi, MD, MS, FACS · Answer

The first thing is to make sure that " breast reduction" is not an "exclusion" in your particular policy. You can check on your policy by calling them. 
Next step is to see a board certified plastic surgeon who is in your network and get evaluated. Then the plastic surgeon will communicate with your insurance company to request a preauthorization or predetermination by sending them a letter, pictures and an estimate of how much breast needs to be removed ( weight). If you meet the criteria, then a letter of approval is sent to you and your physician and you can get it done.

Krishna Vyas, MD, PhD, MHS · Answer

Insurance plans have specific criteria for coverage, often requiring clear documentation of medical necessity for the diagnosis of symptomatic macromastia.
What is symptomatic macromastia?
This condition is linked to symptoms like chronic back, neck, and shoulder pain, skin irritation or rashes beneath the breasts, difficulty finding well-fitting clothing or bras, and restrictions in physical activity. Women with symptomatic macromastia may also face emotional distress due to the physical discomfort and its impact on their daily lives. Breast reduction surgery is often considered a viable solution to relieve these symptoms by removing excess tissue, reducing breast size, and enhancing overall comfort and quality of life. Insurance may cover the surgery if it is deemed medically necessary based on these symptoms and supporting factors.
To establish medical necessity, it is crucial to document attempts at conservative treatments, such as weight loss, physical therapy, pain management, and medication for symptoms like back, neck, or shoulder pain. Many insurance plans will also have requirements for the amount of tissue removal, often based on the Schnur Scale, which considers factors such as body weight, BMI, and body surface area. Your primary care provider can help document these efforts and provide referrals if needed.
Next, schedule a consultation with a plastic surgeon who specializes in breast reduction surgery. The surgeon will evaluate your condition and measure the amount of excess tissue, which is necessary for insurance submission. The surgeon will also provide supporting letters detailing your symptoms and the need for surgery. It’s also helpful to gather letters from other healthcare providers, such as physical therapists. By thoroughly documenting your case and following these steps, you can increase your chances of obtaining insurance approval for the procedure.
Best wishes on your journey!
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

M. Mark Mofid, MD, FACS · Answer

Thank you for your question. The symptoms you are describing are exactly what insurance companies are looking for when deciding if a procedure would be deemed medically necessary. Given your height, weight, and the size of your breasts currently, you are most likely a good candidate for this procedure. I would suggest calling your insurance company to see if they would cover the surgery in the first place. Then you would need to see your primary care doctor who could give you a referral and authorization to see a plastic surgeon in your network who could perform the operation.

Connie Hiers, MD, FACS · Answer

You need to contact your insurance company and see what they will cover and what previous treatment needs to be done. All this, like physical therapy, needs to be prescribed because of neck and back pain from your large breasts.  With most companies, prior approval can be sent to see what would be covered and the required amount to be removed.

Camille Cash, MD · Answer

From your description you are a good candidate for a breast reduction.  Visit with a surgeon who takes your insurance for a consultation.  During an exam your surgeon will take measurements and information to submit to your insurance carrier for review.  Keep in mind that the insurance company often will dictate the minimum amount of tissue that needs to be removed for coverage.

Danielle Atwood, MD, PhD · Answer

Hello,
Most insurances do cover breast reduction surgeries, however not all plastic surgeons take insurance. This is something to ask on the first phone call to schedule your consultation.
Insurance requirements for coverage are first and foremost that this is a medical necessity which is causing you functional limitations and not for cosmetic reasons. They usually want to see longer than 6 months of shoulder grooving from bras, back/shoulder/neck pain for which OTC medications, physical therapy, supportive garments have not worked. Also, rashes under the large breast or infections warrant medical necessity.
Additionally, you or your physician can calculate your Body Surface Area based on your height and weight. This is then used to find the amount (weight) of breast tissue required by insurance to be taken off, called the Schnur Scale. You can find these calculators online. If your surgeon believes you have that much tissue to be removed, it is usually covered without issue. 
However, make sure you get the insurance approval in writing as they frequently approve things verbally with no record and then rescind coverage later, sometimes after the surgery, leaving the patient with a large bill. 
Good luck!

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