Breast Reduction - I am 5'4 and 116 lbs; my bra size is a UK 30g.

I have restricted myself to jobs that allows me to sit more than stand. In the past, when I worked jobs that required lots of standing and walking, I experienced extreme pains and aches throughout my back. For the majority of my adulthood I've had state insurance, I've just recently, in the last 8 months, purchased health insurance from my employer. How do I go about getting a claim started for my insurance company to pay for my breast reduction?

Doctor Answers 7

Insurance coverage for a breast reduction

Hello and thank you for the question.There is a fair amount of variability between insurance companies in terms of coverage. Additionally, not all surgeons accept medical insurance. The first step would be to find a surgeon for your procedure. He/she will then perform a formal history and physical, with photography, and a letter will be sent by the office to your insurance carrier.  A determination will then be made as to your candidacy for reimbursement for the procedure. Warmest Regards,Glenn Vallecillos, MD, FACS

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 29 reviews

Breast Reduction - I am 5'4 and 116 lbs; my bra size is a UK 30g

This topic has been discussed in my previous answers many times and I suggest you review these.  Insurance companies vary significantly in terms of their requirements and guidelines for breast reduction.  In general, you need to have your doctor document your symptoms and also document that you have been under conservative management for a period ranging from 3 to 6 months, depending on the insurance company, with no benefit.  Conservative management includes special bras, physical therapy, gait training, and nonsteroidal anti-inflammatory medication such as Ibuprofen.  Hope that helps.

Ruben B. Abrams, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 17 reviews

Breast reduction and insurance

You will have to ask your insurance company what their criteria are for approval under insurance. Best of luck.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Breast reduction, some advices:

Thank you very much for sharing your concerns with us. 
After having analyzed all the information provided to us, i can realize that you have very large breasts for your height and weight, and can be responsible for head, back, neck and shoulder pain. In the future may cause  permanent osteo-articular damage in the back and shoulders and skin problems (mainly under the breasts). For for this reasons, certainly you need a breast reduction surgery.Kind regards

Emmanuel Mallol Cotes, MD
Dominican Republic Plastic Surgeon
4.7 out of 5 stars 149 reviews

Breast reduction - how to get it done?

Thank you for asking about your breast reduction.
  • I am sorry you have had such problems -
  • Your first step is to go to the web site for Criteria for breast reduction.
  • They may require, for instance, your doctor's recommendation, a trial of weight loss, chiropractic treatment.
  • I know this doesn't make sense - but it's how insurance does it.
  • Make sure you meet these criteria
  • Then call your insurer, speak to a human being to discuss the criteria, the process and anything anything you have missed.
  • Then find on the website the plastic surgeon's on your insurance panel.
  • See the plastic surgeon for a consultation and take the insurance criteria with you.
  • S/he will submit a Letter of Pre-determination to have insurance approve the surgery, based on the criteria.
  • Once your insurance approves the surgery, you need to have it done (usually in 6 months) or the approval expires.
Always see a Board Certified Plastic Surgeon. Best wishes  - Elizabeth Morgan MD PHD FACS

Breast Reduction and Insurance Concerns...

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery; this operation tends to be one of the most patient pleasing operations we perform. Based on your description, it sounds like you may be an excellent candidate for the procedure.  

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. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform.  Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps. Best wishes.

How to get your insurance company to pay for your reduction?

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.

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.