What Documentation Do I Need to Have my Breast Reduction Covered by Insurance?

I have been having back problems since 2006.I started seeing a chiro in 2008, but it got too expensive so I stopped going.Then in 2009 I went to my primary health care provider she also gave me pain pills.I am 5'0 tall and my bra size 38 DDD. So in 2010 I went back to my doctor due to my neck and back hurting so bad i could barely stand.I decided I wanted to lose weight so I went from 203 to 170.Do I need submit all of this to them?I have a rash now is it wise to go to doctor now for documentation?

Doctor Answers 6

Breast Reduction and Insurance Coverage?

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Thank you for the question.

Based on your description you may be a good candidate for breast reduction surgery;  for insurance purposes the more documentation of symptoms you have,  the better.

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.

Best wishes.

Insurance coverage of Breast reduction

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Through the MIB (medical information board), your insurance company should be aware of this. But you should seek a participating physician and have them compose a predetermination of benefits letter to your insurance carrier to discuss you actual level of coverage.

Breast reduction and insurance

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Each insurance company has different criteria for approving breast reduction surgery.  It sounds like you are a good candidate and all that doucmentation should come in handy.  The bes tthing to do is check with your insurance company.

Breast Reduction and Insurance Coverage

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In summary - 5'0 tall, 170 pounds (BMI of 33.3 qualifying you as Obese) with bra size 38 DDD with neck and back pain and under the breast rash.

A private insurance is a contract between you and an insurance company to partially pay (after co-pays and deductibles) for CERTAIN SPECIFIC medical conditions. Large symptomatic breasts may or may not be part of your particular policy, or in their parlance not a covered benefit. If this is the case, it would not make a difference if you were 100 pounds and had 40FFF breasts with pain of all muscles and every other indication in the book - the insurer would NOT be bound to pay for a non-agreed / (pre)paid for benefit.

The first step is to read your policy and see if you do or do not have "Breast Reduction benefits" or similar verbiage. If you do not, you might as well stop here. If you are covered for such issues, get the insurance policy's most up to date list of "providers", or Plastic surgeons who work with your policy. Contrast this list with a listing of members of The American Society of Plastic Surgeons in your area and study their websites. Then visit 2-3 of these surgeons and see what each proposes.

Every insurance company has its own set of requirements for allowing Breast Reduction. Your chosen surgeon would be best to guide you on what your particular insurer wants to see before approving your surgery.

Good Luck

Peter A. Aldea, MD
Memphis Plastic Surgeon

Documentation to support insurance coverage for breast reduction

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Hi SD59980.  Sorry to hear about your troubles.  In order to have your insurance company cover breast reduction surgery, you need to build a case and enlist a PS to write a preauthorization letter for you, attaching photos, which will clearly illustrate how you are inconvenienced by the weight and size of your breasts.  I would suggest that supportive letters from your Chiropractor, Primary Care Physician, Dermatologist, Orthopedic Surgeon, etc. would be very supportive as they validate your functional complaints of musculoskeletal discomfort, heat rashes, limitation of activities.  It is also up to you to provide a history: a) the volume of your breasts do not significantly reduce when you loose weight; b) there are other large busted women in your family; c) your mammograms document "dense breast tissue".  Finally, review your insurance company's specific requirements for breast reduction, as they may specify that your BMI (body mass index) has to be within a certain range.  They may also specify how many grams/side should be removed, as they are understandably unwilling to pay for a procedure, which they deem "cosmetic".  Regrettably, as the criteria become more stringent, less cases will be covered, as is the case in the U.K. where breast reduction isn't a covered benefit.  Good luck.

Lavinia K. Chong, MD
Orange County Plastic Surgeon
4.8 out of 5 stars 58 reviews

Criteria for breast reduction

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Insurance companies have different requirements for approving coverage of breast reduction. They will need to verify whether the procedure is "medically necessary". Usually this involves documentation of neck and/or back pain, shoulder grooving, and rashes under the breasts in addition to large breast size. You should contact your insurance company directly to obtain their specific requirements. Your plastic surgeon may be of assistance in obtaining pre-authorization for the surgery.

Olivia Hutchinson, MD
New York Plastic Surgeon

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.