Am I qualified to get a breast reduction and can it be covered my my insurance?
Doctor Answers 6
Insurances are getting worse and worse regarding paying for reduction surgery. I do it as an outpatient to minimize the cost to my patients. Most are self pay. Call your insurance company and see if they give you a straight answer -- usually they just beat around the bush.
Qualifying for Breast Reduction Surgery
First you should find out if breast reduction surgery is covered under your insurance plan. Asked your insurance representative (or sometimes you can get this information on your insurance companies website) what are the criteria for having breast reduction surgery covered. A lot of insurance companies use the Schnur Sliding Scale (SSS) to determine the minimum amount of breast tissue that needs to be removed from each breast in order to qualify. Using your height of 5'4" and weight of 155 lbs, your Body Surface Area (BSA) is 1.80 m2. For this BSA, the SSS determines that a minimum of 441 grams of tissue should be removed from each breast. This could possibly get you down to a C cup. However, without your photos and without an examination, that would just be an estimate from me. Obtain a consult with a plastic surgeon in your insurance plan for more information. The fact that your breasts don't change much with weight changes and the fact that you are only 20 years old would likely mean that your breasts are made up mostly of glandular breast tissue and less fatty tissue.
Yes, you can get this covered by insurance, depending on what type of plan you have.
I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with and who is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery.
Harvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon
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Even when one knows how much tissue one removes, it is difficult to predict the cup size because bras are not all alike.
Are you qualified for a BR?
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.
What matters is the gram weight to be resected. Historically, the magic number was 500 grams but some carriers, including Aetna, now look for 750 grams. The only way to assess the amount of breast tissue which would remain and the cup size would be in consultation. Since bra sizes are so variable and many women substitute cup for chest circumference, it is impossible to respond to the final question online.
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.