Will Insurance Cover my Breast Reduction Surgery? (photo)

59 inches tall, 102 lbs, extremely slight frame. Bra size is 30E. Neurologist, whom I have visited since 1/2012 because of pain in back, says that breast size is primary etiology of pain and diagnostic tests rule out other causes of functional impairment. Severe restriction of physical activity. Insurer does not have minimum weight to be removed. Plastic surgeon estimates 150 gm per side. Have had two courses of phys ther over 9 months, meds don't alleviate pain, multiple visits to neurologist.

Doctor Answers 14

Insurance Coverage

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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 through Insurance

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Thank you for the question and photo.

Although breast reductions are sometimes covered by insurance, I do not think your surgery would be authorized due to the small amount of tissue that needs to be removed.  Generally, insurance companies have specific guidelines as to how much tissue needs to be removed (usually more than 150 grams).  It won't hurt to submit it for authorization -- best if sent with documentation from other doctors --and see what happens but don't be disappointed if you are denied.

I hope this helps.


Breast Reduction Criteria

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Breast reductions are covered by insurance companies by meeting 2 criteria.  First, you must have symptoms related to the large breasts such as neck, back and shoulder pain or rashes.  Second, you must have the amount removed that meets their criteria.  I have never known an insurance company to authorize a breast reduction of only 150 grams, despite your small size.  I believe you would benefit from a new technique called breast weight transfer.  This technique transfers the weight of your breast from the skin envelope to the underlying muscle.  Muscle is able to support your weight better than the skin and without pain.  You are an excellent candidate for The Ultimate Breast Lift or The Ultimate Breast Reduction.

Best Wishes,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Breast Reduction

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Insurance coverage for breas reduction will vary based on the carrier. Although you appear to have a reasonable chance for coverage some carriers require a lot of documentation and physical therapy while others do not. You will need to see a plastic surgeon who has experience dealing with these issues.

David L. Abramson, MD
New York Plastic Surgeon

Reduction covered by insurance

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It seems based on your comments that you may be a candidate for breast reduction.  Whether or not it will be a covered benefit by your insurance policy is difficult to say.  I would recommend a consultation with a Board Certified plastic surgeon who can help determine medical necessity of the surgery.  A letter will be generated and sent to your insurance company for predetermination.  Any additional information you can provide to accompany the plastic surgeon's letter, such as a letter from your neurologist may help in getting your case approved.  Good luck.

Mennen T. Gallas, MD
Katy Plastic Surgeon

Breast reduction coverage

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Thank you for your question and picture.  Based on your description and symptoms, you seem to be a good candidate for breast reduction surgery.  You need to have an in person consultation with a board certified plastic surgeon at which point in time your medical necessity will be documented with pictures taken and a letter written through your insurance company.  A predetermination for insurance coverage will be made with an estimated amount of tissue to be removed from each breast.  This typically will be performed within weeks of your initial consultation.  You likely will have coverage based on the information you provided.  Best of luck.

Kevin Tehrani, MD, FACS
New York Plastic Surgeon
4.7 out of 5 stars 112 reviews

Will Insurance Cover my Breast Reduction Surgery? (photo)

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Only a PREDETERMINATION letter will give you some security as to possible health insurance benefits for your breast reduction. Find a boarded PS to write this letter for you. Best of luck. 

Breast reduction

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While your symptoms and body habitus are consistent with the possible need for a breast reduction, I doubt your insurance will cover a 150 gm reduction from each side. Usually they require 350-500 gms/side minimum in mmost cases. Of course, an exam in person is key.  Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

You will probably get insurance coverage for breast reduction.

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Based on what you say and on your picture, I think you will have insurance coverage.  I wrote an article about this topic on my RealSelf profile.  You might find it useful.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Breast Reduction Insurance Coverage

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You have done all of the right things to convince your insurance company that the large breasts are giving you significant symptoms.  Most breast reductions remove a lot more that 150 grams per breasts so make sure you and your surgeon have come up with the right plan.  If you are trying to alleviate symptoms you will probably need to remove more than 150 grams but this weight has not been scientifically established.  Make sure you have expressed your desires clearly to your surgeon as to the final size and shape you desire.

Best Wishes

Dr. Peterson

Marcus L. Peterson, MD
Saint George 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.