My currently wear 34G bra. Would I qualify for insurance coverage of breast reduction?

Question

My bra size is 34 g. I am 5'7" and weigh 155 pounds. Based on the schnur scale I would have to have 440 grams removed for insurance to cover. Would I qualify for a breast reduction? Would I have that much tissue to remove? I have been told my breasts are very dense. Does that make a difference?

Richard H. Tholen, MD, FACS · Answer

Based on your stated height and weight, the Schnur formula would require the removal of at least 460g per breast in order to qualify for breast reduction insurance coverage. (That assumes you have the other subjective criteria.)Since 454g = 1 pound, you would require the removal of just over one pound per breast to obtain coverage. One or two grams too little removed means you would NOT qualify and your insurance would deny coverage. This means you would get the ENTIRE bill, even if  you were just barely under the minimum required resection.So take a pound of anything and see how that compares to your breasts, and more importantly, how much breast that would LEAVE BEHIND!Density is relative, since a pound of lead weighs exactly as much as a pound of feathers. No matter the density, you need to have at least 460 (and I would add another 5-10 g just to be on the safe side) grams removed per side.I have found that even though insurers require a certain amount of tissue removal, patients are much more concerned with the amount of tissue that remains.One way I demonstrate this to patients is to figure the Schnur formula based on the patient's height and weight, and once I have the number (in your case 460g), then I give them a 460cc implant and ask them to imagine that amount of tissue removed from each breast, one of which they can hold in their other hand. This will give you the answer, and you can always ask for a "cosmetic" (any size removed you wish) breast reduction or breast lift instead. Of course, you then must pay for elective surgery. Best wishes! Dr. Tholen

Jed H. Horowitz, MD, FACS · Answer

Thank you for your question. Yes, in my opinion you would be a good #candidate for a #breast #reduction surgery. Candidates for #BreastReduction surgery
are women who wish to have smaller #breasts to achieve a more proportional
appearance or to alleviate physical discomfort. Breast reduction can correct
symptoms from excessively #largeheavybreasts that may cause the inability to do
certain exercises, or create back, shoulder and neck pain, poor posture,
bra-strap shoulder indentations and chafing or rashes under the breasts. Women
experiencing these discomforts may benefit from Breast Reduction, also called #ReductionMammoplasty.
Furthermore, large breasts may interfere with normal daily activities or
exercise and will be more comfortable when reduced. Women who feel that their
excessive breast size decreases a sense of attractiveness and self-confidence,
or results in unwanted attention are also candidates. This procedure is commonly covered by insurance
though 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

#PlasticSurgery #BreastReduction
#Insurancecoverage

Every insurance company has their
own policy regarding #reduction coverage. The best thing to do is schedule a
visit with a plastic surgeon who can contact your insurance company for
authorization after performing a #breast examination and documentation of your
symptoms. You should also consider going to your primary physician for an
examination and documentation as well. Insurance companies have a number of
requirements and an examination will be able to determine if you are a
candidate for reduction.

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 i 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 though 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. Best wishes!

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question.  Based on your bra size and height and weight, you should be an outstanding candidate for a breast reduction.  The most important aspect is to find a surgeon you are comfortable with.  With good surgical technique, you could have an outstanding result.  I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.Best wishes and good luck.Richard G. Reish, M.D.Harvard-trained plastic surgeon

Anita Patel, MD, FACS · Answer

To qualify for breast reduction surgery to be covered by your insurance, you have to meet a number of requirements. Having large breasts alone doesn't matter. They will only consider covering breast reduction surgery in patients who are suffering medically due to the large breasts. They want to know what symptoms you have suffered due to the large breasts, how long you have had the symptoms, what measures you took to try to alleviate or lessen those symptoms, and how long you tried those conservative measures. They often ask for photos to document the large breasts, and occasionally will also request documentation that supports what you say you have tried for treatment. For example, if you have tried prescription creams or ointments for rashes below the breasts, they may ask for the doctors record of that treatment. Once you pass all of those requirements, they will want to know how much tissue the surgeons estimates will be removed. While we can estimate the amount to be removed, if the amount that is actually removed in surgery falls short of that estimate, then insurance can deny payment. Actually, even if you meet every single criteria, your insurance may deny payment. At our office, we try to help our patients by submitting to the insurance company for preauthorization, and even if the preauthorization is granted, each preauthorization letter has one sentence at the bottom- saying that just because they authorized the surgery does not mean they will pay for it. Funny, right? The actual criteria and rules do vary from insurance plan to plan, and you can usually find out exactly what the criteria are if you google your insurance company and their coverage for breast reductions. To answer your question about dense breasts- this may make a difference in how much the tissue that is removed weighs. The fattier the breast tissue the less it weighs, whereas more dense breasts tend to have more fibrous tissue which would typically weight a little more. If figuring this out seems to daunting to do on your own, start by seeing a board certified plastic surgeon who has experience doing breast reductions and dealing with insurance (not all plastic surgeons take insurance). They can guide you through the process, and tell you if you have a good chance at getting the procedure covered. I would also recommend asking the surgeon what his/her policy is if you have the procedure and insurance denies payment. You want to know your costs up front in all scenarios, so that there are no surprises. Good luck!

Erik Hoy, MD · Answer

Based on the measurements provided, you may be a good candidate for breast reduction surgery.  Typically insurance companies require that this surgery only be done in cases of back pain, neck pain, shoulder pain, shoulder grooving, rashes beneath the breasts that don't respond to topical medications, etc.  Usually 400-500g removal is required but this varies between insurers.  That typically equates to 2 cup sizes for most women.  Discuss this with you board certified plastic surgeon and your insurance company to determine if this is the case for you.  Best wishes!--Erik Hoy, MD

Steven Wallach, MD · Answer

Best to check with your insurance company to see if you satisfy criteria for approval. Best of luck.

Daniel Krochmal, MD, FACS · Answer

Thank you very much for your question.Usually without pictures it's difficult to make recommendations.  Based on your description, that amount of tissue could be removed, but it depends on what size you ultimately want to be.  For insurance to cover breast reduction, there are other criteria that usually also need to be met (pain, shoulder grooving, specialty bras, trials of physical therapy).  I recommend visiting with a plastic surgeon who will evaluate you in person and discuss your options.  Best of luck!

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