42H to DDD Reduction (Metroplus Healthplan)? (photos)

Question

I have been a 42H since I was 16, now I'm 21. I've been trying to get a reduction from 16, but no doctor wanted to operate on a minor much less one who hasn't breast fed yet. Since I've tried weightless but my breasts has not shrunk. I need a reduction now, the pain is becoming worst and unbearable. Between the lower and mid back pains to the neck and shoulder, it's hard for me to stand at work. I have Metroplus through Medicaid. Is it possible.how hard is it for them to cover my surgery.

Larry S. Nichter, MD, MS, FACS · Answer

From your description it seems as if you are a good candidate for breast 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Emmanuel Mallol Cotes, MD · Answer

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.Respectfully, Dr. Emmanuel Mallol Cotes.-

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Thank you for your pictures.  You should seek non surgical therapy for your neck and back pain from your primary care physician.  If you do not improve with non surgical therapy then you will need a referral to a plastic surgeon for breast reduction.  All the information from both physicians can be submitted to see if you can get your breast reduction covered.

C. Bob Basu, MD, MPH, FACS · Answer

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.Best wishes,Dr. BasuHouston, TX

Sugene Kim, MD, FACS · Answer

Breast reduction may or may not be covered depending on your insurance 
carrier and your breast size. Please check your insurance policy to see 
whether breast reduction is a covered procedure. Often times, insurance 
company will dictate how much breast tissue to be removed. Please visit 
an experiences, board-certified plastic surgeon to learn about the 
procedure, its cons and pros, benefits, and alternatives. Please contact
 your insurance carrier to learn about inclusion and exclusion criteria.
 Best wishes.

Tom J. Pousti, MD · Answer

Based on your description you may be a good 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).You will need to find a surgeon who is contracted with your insurance company and 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 seeking consultation with well-trained/experienced board-certified plastic surgeons.  
Prepare to be persistent.
Best wishes.

Leslie V. Cohen, MD, FACS - Account Suspended · Answer

Based on the information you have provided you may be a good candidate for a breast reduction. It is important that you be in good health, not smoking, and as close as possible to your ideal body weight. In order to have your insurance cover your surgery you would generally need to show that your symptoms are not relieved  by non-surgical treatments, To do this you should see your physician and try physical therapy and medication directed towards treating your back pain. If your symptoms are not improved, your doctor can then refer you to a plastic surgeon who will evaluate you and submit the information from both physicians to see whether your breast reduction can be covered.Best wishes on achieving your goals!

42H to DDD Reduction (Metroplus Healthplan)? (photos)

Answers (7)

More Breast Reduction Questions

I am 18. I have saggy boobs, my nipples point down. I'm extremely self conscious about them. I am a 32 DDD or E. I am 5 feet

What are the odds of getting my Aetna HMO plan to approve a much needed breast reduction?

I was declined by my insurance for my breast reduction? What to do?

I have a small hole in the cleavage of my left breast. Is this normal and should I contact my surgeon? (Photo)

Will BCBS (Federal) cover my breast reduction?

WE SEND PRETTY
EMAILS