How do I get United Healthcare to cover a breast reduction surgery? (photos)

Question

I am 23 and a 32G, but I'm honestly busting out of that. I am 5'2" and weigh 133 pounds. I have recently noticed that my back and shoulders have started to hurt and the pain spreads up my neck, sometimes resulting in headaches. I don't have severe dents where my bra straps sit. Working out has been difficult because my boobs bounce too much. Am I a good United Healthcare candidate? I've looked on their site, but I can't really comprehend what they mean. Please help!

Miguel Delgado, MD · Answer

Insurance can be very confusing! Different policies may have different requirements, your best bet is to find a Board Certified Plastic Surgeon that you feel comfortable with and have your surgeon apply for you. If it is a covered procedure under your policy, you should qualify. If by chance they deny benefits, ask your surgeon to appeal your case, I have gotten several patients approved this way. Good luck!

C. Bob Basu, MD, MPH, FACS · Answer

Every insurance plan has their own unique criteria on whether they will 
cover a breast reduction. More and more, we are seeing plans where a 
breast reduction is not a covered benefit. If it is a covered benefit, 
some insurance plans set a minimum required amount of tissue to be 
remove in order to met their threshold for coverage. Some set the amount
 in relation to your BMI (height and weight). Others require extensive 
medical records documenting neck pain, back pain, and history of rashes.
 The other alternative is to opt for a breast reduction as a self-pay 
option. Start by visiting with a board certified plastic surgeon to 
learn more about your options.Best wishes,Dr. BasuHouston, TX

Josef Hadeed, MD, FACS · Answer

Insurance companies have certain criteria that they utilize when determining whether or not to approve a breast reduction. You might want to check with your particular insurance carrier to see what your policy allows. A consultation with a board certified plastic surgeon can help you to understand what your options are. Their office would then submit the necessary paperwork to your insurance company for authorization. Best wishes.

Robert L. Kraft, MD, FACS · Answer

In terms of height, weight and bra size, you are an excellent surgical candidate. United does impose preauthorization requirements that involve conservative medical management, such as chiropractic or physical therapy, which must be documented. Chart records from these treating providers must be submitted with the request for authorization and the policies mandate set lengths of time during which you must have active treatment, usually a minimum of three months but sometimes up to six months.

Wesley T. Myers, MD · Answer

Depending on your particular health
insurance plan, breast reduction surgery may be considered a covered benefit.
Some insurance carries may cover your breast reduction surgery based on the
size of your breast, your body habitus, and the severity of back, neck, and
shoulder pain caused by your large breast. Breast reduction surgery is
generally considered a reconstructive procedure and may be covered by health
insurance when it is performed to relieve these medical symptoms. Many insurers
determine whether to categorize breast reduction surgery as reconstructive
surgery based on the amount of tissue that will be removed. Breast reductions
involving removal of small amounts of tissue may not be covered by your
insurance. Pre-certification is required for reimbursement or coverage.
Insurance policies vary greatly and a pre-certification is not a guarantee of
payment. I recommend that you carefully review your policy to determine your
coverage for breast reduction surgery.

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.

How do I get United Healthcare to cover a breast reduction surgery? (photos)

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