Would I qualify for a breast reduction? (Photo)

I am almost 21 years old and I have a D, sometimes DD breast size. I am 158 pounds and am only 5 foot 3 inches. I have always had large breasts, and in the past 4 or 5 years have had terrible neck and back pain because of my breasts. I am worried that because I have never seen a doctor about it, that I won't be approved by my insurence company. Would I be someone who qualifies ?

Doctor Answers 4

Breast Reduction covered by insurance?

Under certain circumstances Breast Reduction is covered by insurance. 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Orange County Plastic Surgeon
4.9 out of 5 stars 154 reviews

#breastreduction #insurance #doIqualify

I really cannot answer that question unless I know what insurance carrier you have and whether or not your carrier actually will cover a breast reduction. Since the onset of Affordable Care, many policies specifically write breast reductions out of their coverage policy.If your carrier will cover reductions, each insurance company has specific rules that you must meet to qualify- and they are all different. Most will require a certain number of grams of breast tissue be removed based on your height and weight. Only during a consultation with a board certified plastic surgeon will you know if your breasts are large enough to meet that requirement.You can of course always consider having a breast reduction as an elective procedure. It may be less expensive (depending on your specific insurance co-pays and deductables)

Jack Peterson, MD
Topeka Plastic Surgeon
4.5 out of 5 stars 39 reviews


You will not be able to get your answer here. Your insurance needs to be looked at by the surgeon. A letter will need to be written to get approval. 

Michael Hueneke, MD
Nashville Plastic Surgeon
4.9 out of 5 stars 63 reviews

Would I qualify for a breast reduction?

Thank you for the question. Based on your description, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations we perform.  “Typical” patients who present for breast reduction surgery are women who have disproportionately large breasts, causing problems such as neck/back/shoulder discomfort, postural changes, bra strap grooving, skin irritation/rashes under the breasts, and/or difficulty with activities of daily living and/or exercise etc. There may be both physical as well as psychosocial “stress” caused by the disproportionately large breasts. Reducing breast tissue mass and elevating the breasts on the chest wall tend to improve or alleviate many of the symptoms associated with the disproportionately large breasts. Patients considering breast reduction surgery should also consider the potential downsides (risks/complications) associated with the procedure as well. Poor scarring, for example may be associated with the procedure. Additional surgery may be necessary in the short or longer term for a multitude of reasons. When the time is right, I suggest that you seek consultation with well experienced plastic surgeons who can demonstrate significant experience achieving the types of outcomes you would be pleased with. Ultimately, careful selection of your plastic surgeon will be the most important decision you make. To this end, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery. ***Ask to see lots of examples of their work and preferably speak/see patients who have had similar procedures done. 
Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better. This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.     I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps. Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 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.