Will insurance company cover my DD breast reduction?

Question

I am DD breat size ,my wieght is 134pounds and tall 167 i want to make breast reduction I called the insurance and they says they will approved if i take 1/3 of each breasts . is it will be ok to take 1-3 of each breasts for the reduction???

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

Ronald J. Edelson, MD · Answer

Without photos it is hard to know for sure if insurance will cover the surgery.  I have never heard an insurance company say that one third of the breast needs to be removed. They usually state a specific weight of breast tissue that needs to be removed from each breast, usulayy 400 to 500 grams from each side.  You need to have a consult with a plastic surgeon who will complete the preauthorization process for you. Good luck!

Curtis Wong, MD · Answer

can be expected if you have documentation of your symptoms and problems attributed to your breast weight AND a minimum amount of breast tissue can be removed to fulfill the insurance companies guidelines.  If you have dense breasts, this is easily met.  If you have fluffy breasts, it may not be covered.  Best to see a local participating plastic surgeon for more advice and to see if you would meet the guidelines.

Tom J. Pousti, MD · Answer

Ultimately, you will need to contact your insurance company again to see whether breast reduction surgery is a covered benefit. The response that one third of your breasts will need to be removed does not make sense. Most insurance companies have a specific breast tissue weight removal requirement.  Generally speaking, 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 letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you seeking consultation with well-trained/experienced board-certified plastic surgeons.  
When dealing with health insurance companies, prepare to be persistent.
Best wishes.

Michael Zarrabi, MD · Answer

There are many ways in which breast reduction can benefit the appropriate patient. If you have back pain, neck pain, shoulder pain, grooves caused by bra straps, rash in the fold of your breast, difficulty with exercise or activities of daily living, or poor posture, you may benefit from breast reduction surgery. You insurance company will cover a breast reduction if medically indicated. This means that you must fail conservative treatment of your symptoms for at least three months. This needs to be documented in the medical records. Also there is a certain amount of breast tissue that must be removed during the breast reduction surgery. The amount of tissue is based on a your height and weight.

Steven Wallach, MD · Answer

Every patient is different when it comes to their bra size and body habitus.  An exam in person would help determine what might be appropriate for you.

Timothy Connall, MD, FACS · Answer

Breast reduction surgery is often covered by insurance companies as a medically indicated procedure. As such, patients must have physical problems related to their large breasts, such as neck, shoulder, and back pain and rashes an/or infections in the lower breast skin.  In addition, the reduction of tissue must meet certain criteria for the procedure to be covered.An exact answer to your question is beyond the scope of this forum.  Please see a plastic surgeon for a consultation.  She will be able to give you your options.

Will insurance company cover my DD breast reduction?

Answers (7)

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