Do you think insurance would pay for a breast reduction? I have premera blue cross.

Question

I am 25 years old and 5'2 118 pounds. My breasts are a size 32 ddd. My posture is horrible since it hurts to hold them up all day. I have back aches from them. And running on a treadmill is impossible. It's very embarrassing. I need help...

Dallas Buchanan, MD · Answer

Thank you for your question. You may be a good candidate for breast reduction surgery.  Every insurance company is different in how they allow or cover breast reduction surgery. Most of them usually approve it based on symptoms and a proposed amount of breast tissue that will be removed. As crazy as this sounds, many companies use a formula called the Schnur formula that calculates the amount of tissue needed to be removed by your body surface area (which is calculated based on your height and weight). At 5' 2" and 118 pounds, your body surface area is about 1.53. Based on the Schnur formula, that would mean that you would need to have 260-280 grams (0.57-0.62 pounds) of breast tissue removed per breast for it to be covered by insurance. This is a modest amount and I think could be removed to give you some relief of your symptoms and be covered by insurance as long as you have the symptoms that go along with macromastia (large breasts). You need to seek a consultation with a local plastic surgeon. Only through a good physical exam can they tell you whether you would be a candidate for breast reduction surgery and whether your insurance will cover it. They would submit the procedure to your insurance for approval and see what the insurance says. Good luck to you!

Stuart A. Linder, MD, FACS · Answer

Your insurance will need photos and initial clinical documents of functional problems to determine candidacy

Brian K. Reedy, MD · Answer

Some insurance companies will cover breast reduction surgery, I would suggest calling your insurance company to see what your plan covers.I would also check with your plastic surgeon to see if they participate with your insurance company ,Good luck!

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.

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

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems your disproportionately large breasts cause.  Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval.   Generally, 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.  Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.
 This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.  Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link, helps. Best wishes.

Ronald V. DeMars, MD (Retired) · Answer

It certainly sounds as if you would benefit from a breast reduction. Insurance does sometimes pay, but they make it difficult. Many insurers require you try conservative therapy for at least a year such as Physical Therapy and/or Chiropractic, that you be at a good weight (you obviously are) and then they require an unreasonable weight to be removed from each breast. The only way to know for your specific case is to see an experienced surgeon for a consultation and have that doctor's office contact the insurer with your specific info. then the insurance will make a decision.

Do you think insurance would pay for a breast reduction? I have premera blue cross.

Answers (7)

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