Would I qualify for breast reduction? Overweight? (Photos)

Question

I will have a oritentaion on the 28th with a plastic surgeon in Los Angeles. My doctor said I was overweight and it can interfere with my approval. Is that true? I am 5'2 150lbs. I have the common "large breast" symptoms (pain and redness under breast) I am currently a 36ddd and I want to reduce to a smaller size. (Depends on how much they approve) Can I please get some tips on how to get insurance to cover me? And if you got covered by insurance, what was the process? (Btw i have kaiser)

Urmen Desai, MD, MPH, FACS · Answer

There isn't any way to "get around" the approval process.  It is pretty standard.  I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery, a member of the American Society of Plastic Surgery (ASPS) and the American Society of Aesthetic Plastic Surgery (ASAPS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon

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

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
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Samuel Beran, MD · Answer

Getting insurance coverage for a breast reduction can be notoriously tricky.  Because the difference between a mastopexy and an augmentation is often only the amount of tissue removed, insurance companies often are often putting up barriers to breast reduction coverage.  
Unfortunately, the insurance companies do not often reveal their criteria and both the patient and surgeon are left guessing.  Generally speaking, the worse the symptoms, the lower the BMI, and the greater the reduction amount = more likely to be covered.

Edmund Ek, MBBS, FRACS (Plast) · Answer

Every insurance company is different, and so before you get too far along in the process, I recommend calling your company directly and asking them about what coverage, if any, you may be eligible for. Unfortunately, insurance is notoriously wary about covering anything that can be considered “cosmetic,” especially if there are other ways of going about it (such as losing weight). Good luck!

Wesley T. Myers, MD · Answer

Some
insurance plans have exclusionary clauses that do not cover breast reduction.
Insurance policies vary greatly and even when pre-certification is successful
it is not a guarantee of payment. I recommend you contact your insurance company directly for guidance.

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Unfortunately, dealing with insurance companies is often a challenging task. Your best option to see if your procedure is covered, is to contact your insurer to get details about coverage and requirements before approval for surgery (as you are doing). Given the difficulties of dealing with insurance, you can consider paying out of pocket for the surgery. For our patients, the out-of-pocket expenses for an insurance plan often approximate (or even exceed) the cost for the procedure. You can then obtain documentation from your surgeon to attempt to get reimbursement from your insurer. Any treatment plan should be based on a detailed discussion with equal input from both you and your surgeon.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   Preoperative visualization and surgical simulation with the Crisalix system may help with your decision. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation in person with a qualified board-certified plastic surgeon.  Good luck! 
Best,
  
Jon Ver Halen, MD FACS 
  
Harvard educated plastic surgeon

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