I'm a J Cup with Constant Neck Shoulder Pain. How Can I Get Insurance to Pay Some?

little about me I'm 5ft 7in 175lbs mother of 2. I have always had large breasts making sports horse ridding everything even cook standing painful to neck and upper back frequent migraines too. Well after 2 kids I'm now at a h-j cup size and can't find a 36 h or j bra and I'm so frustrated. I'm working on getting down to a ideal weight for me 150 then considering reduction. How can I get insurance to pay or help pay for this surgery? Also will they do a lift when they reduce or is the separate?

Doctor Answers 12


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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 and Insurance Coverage

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It is possible that your health insurance will cover some the cost of your breast reduction surgery but you will have to check with your insurance carrier to see if it’s a covered benefit. Next, search for a qualified plastic surgeon who is a participating provider. Most likely you will need to obtain a pre-authorization from your insurance carrier prior to your surgery. Each insurance carrier will have different set of criteria and documentation before authorizing a breast reduction procedure. Your plastic surgeon’s office will help you with the process of obtaining the pre-authorization in order to proceed with the surgery.

Insurance Coverage for Breast Reduction Surgery

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It sounds like you would be a great candidate for breast reduction surgery, however it depends on what insurance policy you have. You should contact your insurance company to find out what their guidelines are for coverage as they can vary. Most insurance companies require a minimum of 500 grams from each breast be removed, but many also want documented steps that you have taken to help your condition, such as:

  • good support bras
  • physical therapy
  • analgesics
  • weight loss

So the fact that you are planning to lose weight first is very good, you should be under a doctors care and be sure to have the doctor document all that you are trying to do. See a Board Certified Plastic Surgeon who will know how to help you get pre approval for your surgery. Good luck!

Breast reduction coverage

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From the information that you provided it appears that you would greatly benefit from a breast reduction. This may very well be covered by your insurance company. However, you first need to make sure that it is a covered benefit as several do make exclusions for coverage. The second is to find the list of the criteria for coverage which usually includes conservative therapy such as physical therapy (which as expected, is never a long term solution).

You need to see a board certified plastic surgeon who can examine you and make the appropriate recommendations. If a reduction is recommended, the his/her office can seek to obtain authorization for you and find out that particular insurance company's criteria for coverage.

Breast reduction and insurance coverage

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I know, as do my patients, that no amount of physical therapy, chiropractic therapy, or special bras will make your large breasts smaller or easier to manage! 

Many insurance companies will cover breast reduction surgery. However, a lot of insurance companies really do make patients "jump through the hoops" before authorizing the operation. 

Many insurance carriers require that a patient has:

  • Documented symptoms for 6-12 months recorded in a physician's chart notes
  • Documentation of rashes that have not responded to topical creams
  • Documentation of physical therapy or chiropractic therapy
  • Documentation that you've tried a special bra
  • A letter from your plastic surgeon stating the weight of breast tissue that may be safely removed
  • Height and weight requirements of the patient with respect to the size of the breasts

Don't be discouraged!  If you haven't met all of the above criteria, it is still worth consulting with a plastic surgeon because many insurance companies don't require everything on the above list. In fact many patients and I have been pleasantly surprised to find out that the operation is authorized despite missing some of the items on the above list...

Lastly, I applaud you for trying to get down to your ideal weight prior to the operation. This will only help improve your final appearance, and it may help with healing as well.

Insurance coverage for breast reduction

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At your bra size, you have gigantomastia and your insurance will probably pay for the surgery.  What is required is a letter of preauthorization from a plastic surgeon, accompanied by photographs and a statement of failed conservative medical modalities.  Your insurance company should have its breast reduction criteria posted on its website.  The breast reduction is inclusive of a lift.  I recommend that you see a board certified plastic surgeon who is participating in your insurance plan as this will reduce your out of pocket costs significantly.

Insurance coverage for breast reduction.

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I hope you find this article useful.

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

Breast reduction

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You may be an excellent candidate for breast reduction but withotu an exam it is dificult to say.  As for insurance coverage, it is getting tougher and tougher.  Each insurance company works differently and you have to aske them what their criteria are.

Breast reduction and insurance coverage

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A breast reduction will definitely help alleviate some of your symptoms including the back pain, neck pain, and headaches.  However, each insurance company and each policy has different criteria on what is considered medically necessary.  I would check with your insurance carrier and your specific policy regarding what criteria will need to be met so that your breast reduction will be paid for by insurance.  Once you have chose a board certified plastic surgeon, his/her office may also be able to assist you during this process.

And yes, a lift is a part of the breast reduction surgery.  Good luck!

Lift Is Part Of Normal Breast Reduction

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Your health insurance is likely to cover a breast reduction in your case unless there is an outright exclusion which some policies contain.  Tightening the skin envelope to lift the breasts is a part of all standard breast reduction techniques and you should not be charged additionally for this.

John Whitt, MD (retired)
Louisville 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.