Can Insurance Cover a Breast Reduction Surgery if Your Breast Are Effecting You Emotionally?

I'm 5'2 and 120 lbs. I am a 36 DD, I'm experiencing a little neck pain and numbness in the hand. I'm emotionally drained, I hate having big breast! Can insurance pay for my procedure? If so what steps should I take?

Doctor Answers 7

Insurance and breast reduction

Many insurance companies do cover breast reductions for medical necessity, although different policies often have slightly different requirements for coverage.  Examples are whether or not you have failed "conservative" measures (non-surgical) to relieve your symptoms, or how much tissue is estimated to be removed by your plastic surgeon compared to your body mass index or body surface area.

The first step is to research your specific insurance policy to see if breast reduction surgery is a covered procedure.  Then find a plastic surgeon who accepts insurance (preferably your insurance) and have a consult!  He or she will be able to guide you through the process. 

Insurance Coverage and Breast Reduction

Emotional reasons aren't usually what insurance companies take into consideration for approval of breast reduction surgery, however based on your height, weight and breast size you would most likely qualify. Each insurance company has their own requirements for qualification. It is best to see a Board Certified Plastic Surgeon that specializes in breast reduction surgery. Your surgeon and his/her staff will be able to help you go through the process for pre-authorization. If you get turned down do not be discouraged, most insurance companies allow you to appeal their decision, then it will be reviewed by a physician who usually calls and speaks to your surgeon. I have gotten approval for many of my patients this way. Good Luck!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 76 reviews

Question as to the possibility of insurance covering breast reduction surgery

If an insurance will cover a breast reduction, it is usually based on their somewhat strict criteria based on physical issues rather than emotional ones. These are related to a relationship between your height, weight and the expected amount of breast tissue to be removed as well as symptoms that you may be experiencing such as neck, back and shoulder pains, shoulder grooves, etc.

You need to first see if your insurance company does even cover breast reduction surgery. If so, go see one or more board certified plastic surgeons who can then assess your situation and submit your information to your insurance company for authorization.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 30 reviews

Breast reduction insurance coverage

Based on your description you may be a good candidate for breast reduction surgery; for  physical and emotional reasons.

The best way to obtain insurance coverage for breast reduction surgery involves 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're  working with a well-trained/experienced board-certified plastic surgeon.

Good luck!

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,499 reviews

Coverage Of Breast Reduction For Emotional Reasons

Your insurance company is unlikely to cover your reduction for emotional reasons.  You do sound as if you would be a good candidate for a reduction based on your size and dimensions.  Go ahead and obtain a consultation with a board-certified plastic surgeon who can communicate with your insurance carrier.  You may have to jump through some hoops (trial of physical therapy and pain meds, for example) but hopefully can have your procedure ultimately approved.

John Whitt, MD (retired)
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Can Insurance Cover a Breast Reduction Surgery if Your Breast Are Effecting You Emotionally?

Yes health insurance has a predetermination policy where you see a boarded PS who will examine you and take your breasts photos to send a letter to your company. If you meet the qualifications outlined in your plans policy than you will receive a return letter of approval. Qualifications include height to weight ratios, history of breast pain, back/neck pain, rashes under the breasts. attempted non surgical therapy like a chiropracter or anti inflammatory meds, letters from your primary doctor, orthopedic doctor, psychratrist help. Your first step is to see a boarded PS in your area. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 174 reviews

Insurance coverage for breast reduction.

Insurance Coverage for Breast Reduction
Article by George J. Beraka, MD

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 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.