I would like to know if I would be a good candidate for my insurance to cover a reduction surgery?

Question

I am 24 years old, I am 5'9, and am 215 lbs. I am done having children and my bra size is a 40G. I have had muscle spasms in my mid back for 7 years and have had off and on intense burning pain in my neck and shoulders as well.

Jed H. Horowitz, MD, FACS · Answer

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. 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. However, insurance criteria are becoming more and more restrictive. Pre-authorization by an insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions. Although, we do not accept insurance, our staff will assist patients in obtaining a pre-authorization so they may attempt to be reimbursed for their out of pocket expenses.

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

Wesley T. Myers, MD · Answer

Depending on your particular health
insurance plan, breast reduction surgery may be considered a covered benefit.
Some insurance carries may cover your breast reduction surgery based on the
size of your breast, your body habitus, and the severity of back, neck, and
shoulder pain caused by your large breast. Breast reduction surgery is
generally considered a reconstructive procedure and may be covered by health
insurance when it is performed to relieve these medical symptoms. Many insurers
determine whether to categorize breast reduction surgery as reconstructive
surgery based on the amount of tissue that will be removed. Breast reductions
involving removal of small amounts of tissue may not be covered by your
insurance. Pre-certification is required for reimbursement or coverage.
Insurance policies vary greatly and a pre-certification is not a guarantee of
payment. I recommend that you carefully review your policy to determine your
coverage for breast reduction surgery. I would also recommend that you make an appoitment with a board certified plastic surgeon to discuss your options.

Glynn Bolitho, PhD, MD, FACS · Answer

It is possible that insurance will cover your breast reduction.  If you are enrolled in an HMO you should see your primary care physician and he/she can refer you to a Board certified plastic surgeon.  If you belong to a PPO call your insurance company and check to see if it's a covered benefit and then ask for a referral to participating physician.Some surgeons may not participate in your insurance but would be happy to courtesy bill and reimburse you the insurance payment after surgery but they will ask for payment upfront.  At your consultation the physician will document your medical issues, take photos and submit a letter to your insurance company for approval.   I wish you the best of luck.

Sofia K. Kirk, MD · Answer

It is very possible that insurance will cover your surgery, If it is a covered benefit.  The best thing is to call your insurance company and find out, then if you need a referral, ask your primary care physician to refer you to a Board certified plastic surgeon. The plastic surgeon will do an exam and determine how much breast tissue needs to be resected, and document your medical issues, such as back and neck pain, grooves in your shoulders, and skin irritation, and send it off for approval.  That's really the only way to find out for sure.

Thomas Guillot, MD (retired) · Answer

Insurance carriers vary somewhat in their approach to coverage of breast reduction with symptoms. Some have a flat exclusion in their policy.  Others have specific criteria such as height, weight, and amount to be removed.  Please see a board certified plastic surgeon to evaluate you and send in the necessary paperwork to see if you qualify for insurance coverage with your plan.

I would like to know if I would be a good candidate for my insurance to cover a reduction surgery?

Answers (6)

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