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

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.

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.