Symptoms of neck and upper back pain, irritation under the breasts, failure to improve symptoms with weight loss (if needed), and duration for more than about six months seem to be what insurance companies are looking for when they approve breast reduction. The amount to be removed does not have to be an arbitrarily large amount, e.g., over 500 cc, in the scientific literature, but some insurance companies may still try to put a minimum number to give approval. Patients who want to try to get insurance company coverage need to have a personal consultation with a board-certified plastic surgeon, and have a letter describing the factors above and usually photographs sent in.
Kaiser is it's own insurance company, and you should go in to see the plastic surgeon there and you can find out directly. Every insurance company deals with the issue as they wish, there are no standardized rules or regulations for this. Your plastic surgeon can help you provide them the needed documentation.
If you want any insurance coverage, you must get them to approve it in writing before having the surgery.
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.
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.
Every insurance individual policy is a little bit different. You can simply call your Kaiser insurance carrier and ask them for the specific requirements for your policy. The general thing that most insurance companies want to know is if the size of the breasts are causing you to have issues that are affecting your day to day activities. This could include back and neck pain or problems with rashes of the skin under the breasts. You will need documentation of the severity and duration of these complaints and then documentation of the non-surgical treatments that you have tried that have failed (support bras, anti-inflammatory medications, heat and cold application, exercises, etc.) Many insurance carriers rely on a scale based on your height and weight to determine how much breast tissue needs to be removed in order to qualify for coverage. These are all things that you can discuss with the plastic surgeon that you choose. Best of luck.
The only way you will know for sure is to ask for a referral to a plastic surgeon at Kaiser and see what they say. To me it looks like more of a cosmetic lift as opposed to a reduction, but it doesn't hurt to ask.
It is very possible that Kaiser will cover your breast reduction surgery, but it will depend on their guidelines. You need to see your primary care physician and get a referral to a plastic surgeon. Good Luck!!
There is NO way we over the internet could know. Best to seek IN PERSON evaluation with a Kaiser PS. You are in an insurance collective that has rules of covered breast reduction surgery.
I have no experience with the Kaiser hospital in your area, but in Portland the Kaiser hospitals have several plastic surgeons on staff that do breast reductions regularly. Of course you have to meet their requirements so it seems it is time for you to get a consultation.
Since you have Kaiser Insurance you will need to be referred by your family MD at Kaiser for evaluation by a plastic surgeon at Kaiser and if he/she feels you are a candidate you should have no trouble getting your surgery done.
Based on your description and pictures you may be a great candidate for breast reduction surgery; it is one of the most patient pleasing operations we perform. If you are not at your long-term stable weight, it will be in your best interest to drop weight prior to surgery.
As you think about breast reduction surgery make sure you do your homework and understand the potential risks and complications associated with the procedure. Unsatisfactory scarring is one of the potential complications. Make sure you also understands that further surgery may be necessary in the future (for example if the breasts were to grow in size again).
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 seek consultation with well-trained/experienced board-certified plastic surgeons.