Would I qualify for a medically necessary breast reduction? (Photos)

Hello. I am 28 years old and wear a size 36 DD bra. My breasts are unsymmetrical and very large which causes me pain daily. I haven't even gone to bed without a bra since I was 13. At the time my breasts developed I went from a B cup to a D in a very short time at the age of 13. They have always been droopy. My breasts have caused me to have very low self esteem, and since they do cause a lot of discomfort would insurance cover a reduction?

Doctor Answers 9

Would I qualify for a medically necessary breast reduction?

I have reviewed your photos. I would recommend having a consultation with a Board Certified Plastic Surgeon and he or she can gain authorization for an insurance covered breast reduction procedure.


San Francisco Plastic Surgeon
4.4 out of 5 stars 7 reviews

How to find out if your reduction will be covered by insurance?

You must see a local plastic surgeon who participates with your insurance program.  Schedule a consultation and it will be determined whether your excision would qualify.  From your photos, it appears so but some breasts are fluffy so it takes an exam to really determine whether you qualify or not.

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

Do I qualify for Breast Reduction

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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Would I qualify for a medically necessary breast reduction?

From your history of pain, asymmetry, bra size and photos, I believe you would be a good candidate for a breast reduction procedure.  Each health insurance company has their own individual criteria regarding whether or not a patient would qualify for having  breast reduction covered under their health plan.  The criteria can include the weight of the tissue removed, the weight, height, and breast photos of the patient, if conservative treatment options have been tried (support bras, etc), the length of time the symptoms have been present, and possible medical evaluations by specialists other that the treating surgeon.  Although, the final determination is made by your health insurance company, from the information you have given, I believe your company would probably approve your surgery.  Seek out a board certified plastic surgeon with extensive breast reduction experience.  Best wishes, Dr. Lepore

Vincent D. Lepore, MD
San Jose Plastic Surgeon
4.9 out of 5 stars 50 reviews

Insurance Coverage for Breast Reduction

Thank you for your pictures. In my opinion, you may be a candidate.  You will need to see your primary care doctor for evaluation of your neck and back pain.  If he/she thinks you need a plastic surgery consult then they will refer you.  Once you see a plastic surgeon, he/she will decide if you are a reasonable candidate.  All these medical visits can be submitted to your insurance company for approval.  Then and only then will you know with more certainty if your insurance will cover this. Best wishes.

Would I qualify for a medically necessary breast reduction?

Thank you for your pictures and questions. It is possible that if you have symptomatic macromastia (large breasts), which it sounds like you do, that insurance may cover a breast reduction. This would depend on your physical exam (including your height and weight ratio) and your specific insurance and coverage plan. Most insurance companies require that a certain amount of breast tissue be removed to be covered. If that is the case, you have to be ready to be whatever size that dictates, which may not be optimal. Make sure you see a plastic surgeon in your area who is familiar with doing breast reduction procedures for insurance and it is always a good idea to get a few consultations before proceeding.

Best of luck!

Insurance coverage for breast reduction surgery

Based on your history and photographs there is a reasonable likelihood that breast reduction surgery would be covered by your health insurance. A definitive answer would require a consultation with a plastic surgeon. If the surgeon determines that you may qualify for insurance coverage a request for pre-authorization can be submitted to confirm your benefits. I hope this is helpful and good luck on you quest.

Wayne I. Yamahata, MD
Sacramento Plastic Surgeon
4.9 out of 5 stars 41 reviews

Breast reduction and insurance coverage

In general, if you have large breasts, and symptoms referable to your breasts, such as back pain, neck pain, or rashes, you will likely benefit from a breast reduction.  Unfortunately, the criteria that insurance companies use to determine whether or not they will cover the procedure is variable.  Furthermore, many insurance companies will require a specific amount of breast tissue be removed in order for them to cover the procedure.  There is no evidence that removing a certain amount of tissue is necessary for symptom relief.  Some times it takes several appeals before insurance companies will cover the surgery.  Based on your symptoms and photos, I would conclude that you ab breast reduction is medically indicated.  Consult with a board certified plastic surgeon who will advocate on your behalf.

David S. Chang, MD
San Francisco Plastic Surgeon
5.0 out of 5 stars 4 reviews

Insurance

Thank you for the question and every insurance company has it's own criteria for coverage so start the process by seeing your primary and a board certified plastic surgeon in your area.

Dr. Corbin

Frederic H. Corbin, MD
Los Angeles Plastic Surgeon
4.9 out of 5 stars 59 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.