I'm very small woman, 4'11. I weigh 130 pounds with DDD breasts - Would Insurance cover my Breast Reduction?
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Doctor Answers 5
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Gary Horndeski, M.D.
Would Insurance cover my Breast Reduction?
It sounds like you have been dealing with breast hypertrophy (breasts too large for your frame) for many years. This problem can cause significant physical and psychological distress for young ladies. Breast reduction surgery is an operation that is associated with a very high patient satisfaction rate (usually almost instantaneous gratification).
Unfortunately, online consultants will not, with any degree of certainty, be able to predict whether your procedure will be covered through health insurance. It will be in your best interest, for many reasons, to achieve a long-term stable weight prior to proceeding with the breast reduction procedure.
I would suggest that you continue to meet with well experienced board-certified plastic surgeons to discuss options. Communicate your goals clearly; I would suggest that you do not base your communication on achieving a specific cup size. As you know, cup sizes will vary from one bra manufacturer to another. Therefore, a discussion is legal based on achieving a specific cup size can be misleading and/or the source of miscommunication/dissatisfaction.
For most patients, I recommend that they try to decrease the size of the breasts such that symptoms are relieved as much as possible; yet the breast size remains proportionate to the remainder of their torso. Goal pictures may be helpful during this communication process.
I hope this, and the attached helps.
Insurance Coverage for Breast Reduction
Insurance companies vary quite a bit on their criteria for medical necessity. Generally they need to know that large breasts are causing physical symptoms, that you have sought non-surgical means of dealing with symptoms, and that you meet the "body surface area requirements." They take your height and weight and put those numbers into a formula that calculates your body surface area. For a given BSA, their tables describe the amount of weight that must be removed per breast in order for insurance to cover. You will need an in person consultatin to help with that determination.
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Insurance coverage for breast reduction
Insurance coverage can be tricky to obtain. It will help your case to demonstrate continued symptoms and large breasts despite some weight loss although it may not be necessary to lose 20 lbs to do so. Getting a plastic surgeon to write a strong letter (provided he or she feels that you are a candidate for the surgery) and possibly getting a note from your primary care doctor can be very helpful. Good luck!
Insurance and breast reduction
It sounds like you've already gone to the insurance route once, but it might be helpful to go through it again with a different doctor. But we cannot tell without an exam how much to remove.
Your surgeon can estimate how much would need to be removed. Whether you need to lose weight depends on how the insurance company determines eligibility.
Some companies don't cover reduction, others require specific symptoms (rashes, pain, shoulder notching) or treatments (hoops to jump through) to be done before authorizing reductions.
Your sense or proportion isn't a medical reason for reductions.
They usually require you be normal in weight for your height (normal BMI). Good luck.
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.