Candidate for Breast Reduction Surgery? 5'8 and 155 lbs. 32H and sometimes 34I bra. (photos)

Question

I am in physical therapy 2x weekly for constant neck/shoulder pain. I have numbness and tingling in my fingers. I was approved for BR surgery in October of last year. I was looking to be a C cup.In December, my insurance denied me for the procedure. They told my surgeon I needed MINIMUM 400gr removal from each side. Per my surgeon, this would likely be what I was asking for in terms of size. He attempted to explain this to my healthcare provider, BCBS, and they yet again denied me.

Robert Cohen, MD · Answer

Based on your symptoms and photos, you definitely sound like a good candidate for breast reduction, although it can be difficult to know how much weight will be removed per breast and if this will meet your insurance criteria.  Certainly try to see if your insurance provider will change their stance, but if they don't, I absolutely think the out-of-pocket costs for surgery will be well worth the improvement in your physical health and appearance. Good luck!

Larry S. Nichter, MD, MS, FACS · Answer

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
#breastreduction#reduction

Nina S. Naidu, MD, FACS · Answer

Hi, thank you for your question.  You appear to be an excellent candidate for breast reduction surgery.  Getting insurance to cover breast reduction surgery is frustrating, at best.  You may be able to perform a second-level appeal with your insurer (ask your surgeon if this is possible).  Prior to doing so, it's best to obtain more documentation of your symptoms from an additional provider, such as a physical therapist or chiropractor.  If you do need to pay out of pocket, you may be able use a financing company such as Care Credit to help spread the costs out over time.Best wishes and good luck,Dr. Naidu

Jean Paul Giudicelli Saba, MD · Answer

Hi, thanks for sharing your concern and photos with us!
First I want to congratulate you for making this important decision. Deciding to get an aesthetic procedure to change your body and get a new life style is a big step!
  
Looking at your photos I might say that you´ll be a great candidate to get a breast reduction because you have enough tissue to reshape to reduce and lift it. Before all this, of course, you need to get a complete medical evaluation and laboratory exams to check everything is fine. For us your safety, always, is going to be first.
  
Have a great day! 
  
Dr. JPG

Steven Wallach, MD · Answer

If your insurance company has denied you, you can always pay for it yourself.  Now you are not limited to only see a doctor in your plan.

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems your disproportionately large breasts have caused. Based on your description, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations to perform.  
 “Typical” patients who present for breast reduction surgery are women who have disproportionately large breasts, causing problems such as neck/back/shoulder discomfort, postural changes, bra strap grooving, skin irritation/rashes under the breasts, and/or difficulty with activities of daily living and/or exercise etc. There may be both physical as well as psychosocial “stress” caused by the disproportionately large breasts.
Reducing breast tissue mass and elevating the breasts on the chest wall tend to improve or alleviate many of the symptoms associated with the disproportionately large breasts.
Patients considering breast reduction surgery should also consider the potential downsides (risks/complications) associated with the procedure as well. Poor scarring, for example may be associated with the procedure. Additional surgery may be necessary in the short or longer term for a multitude of reasons.
When the time is right, I suggest that you seek consultation with well experienced plastic surgeons who can demonstrate significant experience achieving the types of outcomes you would be pleased with.
 Once you have chosen your plastic surgeon carefully, it will be important for you to communicate her goals carefully as well. If I were seeing you in consultation, I would ask to look at your goal photographs; after doing so, I would be able to help you with a prediction of what you might expect in terms of anticipated weight of tissue removed. ***Keep in mind however that there is no specific/reliable correlation between the amount of tissue removed and cup sizes achieved.
In your case, given your concerns, I would suggest that you spend more time communicating your goals/questions/concerns directly with your plastic surgeon before making final decisions.  Ultimately, you will want to feel comfortable that your plastic surgeon has a significant/demonstrable experience achieving the types of outcomes you will be pleased with.  In terms of dealing with the insurance company;  ongoing persistence may be productive.  In other words, letters of appeal etc. may be necessary.Best wishes with your efforts and for an outcome that you will be very pleased with.

David E. Berman, MD (retired) · Answer

i now do all of my breast reduction privately so i don't have to deal with the insurance companies. you will likely be very pleased with the results form a BR.david berman md

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Unfortunately, dealing with insurance companies is often a challenging task. Your best option to see if your procedure is covered, is to contact your insurer to get details about coverage and requirements before approval for surgery (as you are doing). Given the difficulties of dealing with insurance, you can consider paying out of pocket for the surgery. For our patients, the out-of-pocket expenses for an insurance plan often approximate (or even exceed) the cost for the procedure. You can then obtain documentation from your surgeon to attempt to get reimbursement from your insurer. Any treatment plan should be based on a detailed discussion with equal input from both you and your surgeon.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   Preoperative visualization and surgical simulation with the Crisalix system may help with your decision. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation in person with a qualified board-certified plastic surgeon. Good luck! 
Best,
  
Jon Ver Halen, MD FACS 
  
Harvard educated plastic surgeon

Candidate for Breast Reduction Surgery? 5'8 and 155 lbs. 32H and sometimes 34I bra. (photos)

Answers (8)