Could I get my Breast Reduction, Tummy Tuck paid for by insurance if my doctor refers me for medical reasons?

Doctor Answers 6

Could you get your BR, TT paid for by insurance?

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.

Orange County Plastic Surgeon
4.9 out of 5 stars 159 reviews

Breast reduction is covered by insurance but true tummy tucks are not

as mentioned by Dr. Nadeau.  And to have a reduction covered, certain minimums must be removed determined by your height and weight so your breasts need to be excessively large or dense so you can meet those minimums.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 32 reviews

Insurance coverage for breast reduction and abdominal surgery

Breast reduction is often covered by insurance depending on the size of your breasts as well as your height and weight and the symptoms you are experiencing. Each insurance plan is slightly different in their requirements- you can look up your specific benefits to get an idea of whether you may qualify.

Insurance does not pay for a tummy tuck, but they will often pay for removal of excess skin of the abdomen (there are some subtle differences to these procedures your plastic surgeon can explain) if you are having symptoms from skin that hangs over your waistline such as frequent rashes.

I would encourage you to schedule a consultation in your area to discuss whether these procedures may be covered for you. Best wishes, Dr. Nadeau

Meghan Nadeau, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 5 reviews

Could I get my Breast Reduction, Tummy Tuck paid for by insurance if my doctor refers me for medical reasons?

Breast reduction is sometimes covered by health insurance, although the insurance companies are making this more difficult every year. Tummy tuck is not an insurance covered procedure. You can call you health insurance to find out their criteria for breast reduction coverage but the best thing is to see an experienced consultant for an exam. The surgeon's office will then communicate with the insurance carrier to determine your coverage. Breast Reduction and TT can be done at the same time if you wish. 

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 27 reviews

Could I get my Breast Reduction, Tummy Tuck paid for by insurance if my doctor refers me for medical reasons?

Thank you for your questions. If you meet the medically necessary criteria for breast reduction surgery, which is determined by your specific insurance company and policy, then your breast reduction could possibly be covered by insurance. However, there is no medical reason to have a cosmetic tummy tuck, so that procedure would not be covered by insurance. There have been multiple people who have tried to come up with "medical reasons" for a tummy tuck, but it is never successful. 

Hope this helps!

Dallas Buchanan, MD
Spokane Plastic Surgeon
5.0 out of 5 stars 30 reviews

Could I get my Breast Reduction, Tummy Tuck paid for by insurance if my doctor refers me for medical reasons?

Thank you for the question. You will likely have most success having an insurance company cover breast reduction surgery (best to check directly with your specific insurance company regarding your policy). I have never had an "insurance" entity authorize  tummy tuck surgery.  This operation is not considered medically necessary. 

Sometimes, however insurance companies will cover excision of a lower abdominal wall skin/apron;  this operation is called a panniculectomy. The panniculectomy operation involves excision of the lower abdominal wall pannus or overhanging skin/adipose tissue. It is not considered an  aesthetically driven procedure;  it is often performed to help with concerns such as skin breakdown, infections/rashes… 

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,502 reviews

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.