Do I need to be referrered to a PS by my PCP in order to have my insurance cover a breast reduction surgery?

Question

Like many women, I have struggled with back, neck, and shoulder problems since high school due in large part to having DDDD breasts. Since I want the surgery for medical reasons and have already done years of chiropractic and a year of physical therapy, I'm hoping insurance will cover it. I'm wondering though if I need a referral, or if I can just have a consultation and provide my therapy records. Thank you!

Vincent N. Zubowicz, MD · Answer

Great question! Whether or not you need a referral is actually based on your insurance plan and you can check with them to find this out. If you have one, you would provide it to our office, but there is more that is required. If you have previous progress notes, they are helpful, but it is important to make sure the documentation notes that you believe the pain/problem is associated to the size of your breasts. In addition to this, you will need documentation of conservative treatment and a recent mammogram within the last year if you are over the age of 40. Call our office at any time so that one of our coordinators can talk you through these steps and they even have a document to send via email that outlines the requirements as well.

Randal Haworth, MD, FACS · Answer

With today's insurance plans under the ACA, less and less insurance companies cover breast reduction surgery despite if you may have symptoms such as painful bra strap grooving, neck, shoulder and back pain overly large breasts. However, I suggest contacting your insurance company and asking exactly what is and isn't covered in regards to treating macromastia with a breast reduction.  If they do offer coverage then ask for a list of in network providers whom you can then contact to set up an appointment and consultation with to address your concerns.

Kenneth Hughes, MD · Answer

Read your medical insurance certificate of coverage which will state whether a referral from your PCP is required for a consultation with a board certified plastic surgeon which may have to be in their network of preferred providers. BRs which are medically necessary (i.e. you suffer back, shoulder, and neck "pain" with DOCUMENTED medical attention over a period of a YEAR) are typically covered by medical insurance. If not, your insurance company may try to deny you based upon a lot of things such as weight, lack of enough tissue that should be removed, lack of symptoms, and lack of previous medical management.Kenneth Hughes, MD, Board Certified Plastic SurgeonLos Angeles, CA

Edward S. Gronka, MD · Answer

My advice would be to call the plastic surgery office that you are choosing to go to and ask them.  Their staff should be quite knowledgeable about what requirements are needed to have the consultation and even the surgery. It's also a good test of the office to see how  efficient they are.

Robert Stroup, Jr., MD, FACS · Answer

Best to check the terms of your particular health insurance policy to determine whether you require a primary referral to see a specialist (Plastic Surgeon).  Some policies require a referral and some do not.

Do I need to be referrered to a PS by my PCP in order to have my insurance cover a breast reduction surgery?

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Do I need to be referrered to a PS by my PCP in order to have my insurance cover a breast reduction surgery?

Answers (7)

Answer: Breast reduction referral

Answer: Breast reduction referral

Answer: PCP referral required?

Answer: PCP referral required?

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Recommended reading

Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.