What Insurance Companies Cover Breast Reduction?

Hello yes I need some advice I am 19years old and last time I got measured I was a size F now I am pretty sure they grew alot since I was last measured I just had my second child on april 21, 2011 I am in so much pain my back is hurting so badly that I can barely walk or move sometimes. I am 5'5. I was seeing if anyone knows any insurance company that can cover for a breast reduction. I really need it I take pain killers but none of them help at all with the pain, I also tryed a heating pad nothing I really can't deal with the pain anymore I barely can hold my one aughter because she to heavy it makes the pain worse and I dont like that I cant even hold my daughter because of my breast being to big it causing the back pain.

Doctor Answers 7

Insurance Varies as to coverage for Breast Reduction

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 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.

Insurance and breast reduction

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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. Basu
Houston, TX

Breast Reduction through Insurance

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Thank you for your question.

Insurance companies do cover breast reduction surgery but each has their own criteria for authorization.  It helps to have documentation from other physicians stating that the size of the breasts are causing you neck, back and shoulder pain.  In my practice, I send a letter as well as photos of the patient to the insurance company for authorization.

Best Wishes!

Breast Reduction - What Insurance Companies Cover Breast Reduction?

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Hi brittany_mx,

Most insurance companies "cover" breast reduction surgery when appropriate, but there are a few issues to consider.

First, you have to check your own policy since each company is different and has its own rules; some may specifically exclude breast reduction.  I am not aware of any blanket policies like that, but it merits checking carefully.

Next, each company has its own requirements as far as what it considers an indication for the surgery.  You may have to be a certain bra size, height and weight combination, you may have to have had conservative treatment for a while, etc.  You'll need the help of a plastic surgeon to help you contact your insurance company to see what is necessary in order to get approval (often termed a "precertification").

Finally, you'll need to find a surgeon who's willing to accept what your insurance company considers appropriate compensation as payment for the surgery.  You can start by finding someone who participates in your insurance company or, if that's not possible, then you can call around to find a surgeon who will accept payment if you have out-of-network benefits. 

If this sounds complicated and like there's a lot to do - you're right.  But that's the way it is with insurance companies and reimbursement for breast reductions....so you're better off knowing that ahead of time.

I hope that this helps, and good luck,

Dr. E

Breast Reduction and Insurance Coverage

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Yes, insurance companies can cover breast reduction, which from your description of symptoms is something that can greatly improve upon your quality of life. Getting insurance to cover the surgery can be tricky, but it starts with you: contact your employer and discuss insurance with human resources. They can tell you what is in your plan in regards to breast reduction surgery. If you don't currently have insurance, then you will need to find out this information for whatever company you go with.

Once this is squared away, insurance qualification is based on symptoms: back/neck/shoulder pain, shoulder grooving from bra straps, and infections/irritations in skin underneath your breasts. Photo evidence of your large breast size is also something your future surgeon will need to submit to insurance as well. Any previous therapy- chiropractors, massages, medicines, antibiotics- should also be documented to prove that you have sought after other conservative measures which have not solved your symptoms as well. Good luck and congratulations on the new baby.

Derek Lou, MD
Houston Plastic Surgeon
5.0 out of 5 stars 11 reviews

Insurance Coverage of Breast Reduction

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Re "I was seeing if anyone knows any insurance company that can cover for a breast reduction" .

The vast majority of medical insurance companies cover breast reduction surgery but have different requirements you must meet BEFORE they will agree to partially pay for it (minus your copay and deductible). You must know that many have a pre-existing condition clause, which means you may have to be on the insurance for over a year before they would consider you eligible for this service.

It is best to discuss this with the HR person at your job.

Good Luck.

Dr. Peter A Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon

What Insurance Companies Cover Breast Reduction?

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Mo9st companies have a policy to cover breast reduction surgeries. You need to contact your insurance plan to see the steps needed to be pre approved. 

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.