What is my First Step to Getting my Insurance Company to Pay for a Breast Reduction?

Coverage of the procedure varies widely from one insurance policy to the next. Many insurance companies will cover if you have 500 grams of excess breast tissue (about 1 lb) per side and rarely some may
cover as low as 350 grams. However some companies may require a kilo or more.
 This being said before you go forward with surgical procedures you may
want to see your primary care physician to see if they have any other recommendations and such as therapy or medications. Many neck and back pain symptoms can be treated very successfully with
strengthening of the spinal supporting musculature and this may be required by your insurance company.  This requires some
time and effort but may provide a lifetime of benefit.  

Insurance companies usually want to see a record of having been treated by nonsurgical methods for
at least six months and not getting improvement with conservative treatments.
 This usually means that you have tried diet and exercise, medications and
possibly therapy or chiropractic and have not gotten adequate relief.  The next thing to
do is get an exam with a board certified plastic surgeon with a good
reputation. He should be able to perform an exam to tell exactly how much
excess breast tissue you have.  Then the surgeon will write a letter to the insurance company
and see if they will give approval for the surgery. The insurance company will
send both you and your provider a letter with their decision within a few weeks
in most cases.  Many patients are able to get insurance coverage for the
procedure, but if you do not qualify many places offer a significant reduction
in the price for out of pocket cases that are paid in advance.  Best of
luck on your journey

The first would be to visit with your primary care doctor to establish non surgical treatments. If these treatments fail then they will be documented. Then referral to a PS can be made to see if you are a surgical candidate. This will establish a very reasonable course of action so that the insurance  company will less likely deny your claim  

Dr ES

First step is to call your insurance company, in Ontario this is OHIP, and request the criteria for breast reduction coverage in your area.

Some of the criteria might include:  patient symptoms related to breast size (from a D cup or larger), shoulder, neck and back pain, under breast skin inflammations, and shoulder grooves from the bra.

It is also a good idea to meet with a board certified plastic surgeon for a consultation to discuss your reasons for wanting a breast reduction.  They will guide you through the application process.

 

Thank you for the question.
It may or may not be necessary for you to meet with your primary care physician, depending on what type of insurance you have.
Regardless, obtaining 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 are consulting with  well-trained/experienced board-certified plastic surgeon.
Also, prepare to be persistent. Ultimately it will likely be worth it; breast reduction is one of the most patient pleasing operations we perform.
 

In my years of experience; most insurance companies want to know what conservative methods of treatment you have been tried before seeking surgery. Documentation of your physical complaints of back and neck pain, curving of the spine, grooving in the shoulders, rashes beneath the breasts along with letters from your primary care physician, gynecologist, chiropractor or physical therapist recommending surgery to alleviate your symptoms, are all helpful when determining coverage from your insurance company. Lastly, you need to consult with a board certified plastic surgeon who will submit a letter of predetermination to your insurance company on your behalf; providing them with your height, weight, bra size, an estimate of grams being removed from each breast and photographs for their review for determination of benefits. 

First, you might want to touch base with your insurance company to see what their policy is for approval. They may need medical records for treatment of back of neck pain.  They may want photos, breast size, your weight, etc.. Good luck.

While seeing your primary doctor first is always a good idea, seeking a board certified plastic surgeon who performs many breast reductions on patients like yourself is most important. You surgeon should be your best advocate to ask for a medically necessary procedure to be covered. In my practice we work diligently with patients and insurance companies to provide coverage after patient is evaluated and medical necessity is confirmed.

To add to what has already been said here, each insurance company has its own rules and standards and they can be quite different, honestly depending on the whims of the medical director. Most medical review personnel do not have surgical backgrounds and are applying what are supposed to be guidelines as gospel, with little understanding. Step 1 is to read your insurance company's guidelines. All insurers post these on their websites or you can call and request a copy. Step 2-read the guidelines critically. If they set standards in terms if height and weight, unless you have gigantomastia, meaning not DD but G or H cup breasts, realize that the message is that you will not be approved without weight loss, so pursue that first. Similarly, if the insurance company requires medical management, such as physical therapy, read the standard. It is usually three to six months, not two or three treatments. If you do not go through the protocol, which isn't designed to make it easy, you will not be approved. Step 3-documentation. Letters no longer suffice. Insurance companies want medical records so it is important for you to make sure that your complaints to the primary physician or gynecologist are documented in your chart. Similarly, expect to have the complete record accessible to your plastic surgeon. If you had PT for a foot problem, the insurance company won't accept a statement that you had PT. They will want proof of the modalities, etc. Step 4-it is important that your plastic surgeon be forthright about whether he will support your efforts with a well written preauthorization letter. As an in network doctor, I am poorly paid for breast reduction, one of my favorite procedures because of the high satisfaction rate. Some doctors will not advocate for patients because they have a lot to gain from a denied case which becomes fee for service at fair market value, which is at least 5x what the insurance company pays. Step 5-if your doctor honestly believes at the denial was erroneous or arbitrary, file an appeal. At a level 2 appeal, the burden is on the patient but the insurance company must have the case reviewed by a specialist in the same field, not my favorite medical director, the pediatrician!!! Good luck. Dr K

There are many issues with respect to insurance (you can always pay for the surgery on your own, but that may not be necessary.  Or desirable!).  Each insurance company is different, and each has its own rules with respect to "coverage."  You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

Either way, you'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.  You should, of course, meet with a few plastic surgeons to see what they recommend, and make sure you're informed about the procedure and its risks so that you can proceed knowledgeably.  If you do all of this you'll be most likely to have a result you'll be happy and comfortable with.

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.

I hope that this helps, and good luck,

Dr. E

 Hi.

I hope this article is useful to you.  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.