How can you tell if your insurance company will cover a breast reduction?

I am a 36G about 145 pounds 5"3/ Just curious if there are ways to show medical need to prove you do suffer pain? Also, is there a certain procedure that could help the scarring and minimize it? When you do the reduction is there any way to do a "reverse tummy tuck" like tuck the skin UP where the scars are going to be anyways?

Doctor Answers 3

Will Insurance cover your BR?

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.


Orange County Plastic Surgeon
4.9 out of 5 stars 154 reviews

Breast Reduction Covered

Every insurance company is different and some are more stringent on what they do or do not cover. In general, breast reduction is considered medical if the patient suffers from back pain, shoulder pain, neck pain, has bra strap grooves, suffers from rashes under the breasts, etc. Many insurance companies want to see that you have tried to deal with these problems- whether it was seeing your PCP or your Ob/Gyn for the rashes under your breasts, or whether you've been seen by a Chiropractor or by physical therapy for your back pain. They want to know that you've tried to loose weight without a difference in your breast size or your symptoms. They want to know that you've tried special bras and these have not helped with your symptoms. Usually your plastic surgeon will write a letter and send pictures to your insurance company to obtain prior approval. Having additional documentation from another physician or healthcare provider is also helpful and shows your insurance company that you have tried medical management prior to proceeding with surgery.

Also, it is important to note that based on your height and weight, your body surface area is calculated. Pending your body surface area- your so called Schnur score is calculated which is the amount of breast tissue that needs to be removed from each breast in order for your insurance to cover the breast reduction.


In general, breast reduction patients tend to be the happiest patients.

Good Luck with your surgery!

 

Helen Perakis, MD
Nanuet Plastic Surgeon

How can you tell if your insurance company will cover a breast reduction?

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery; this operation tends to be one of the most patient pleasing operations we perform.

Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.

This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. 

Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps. Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,485 reviews

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.