Breast reduction & CalOptima insurance?

Question

Hello, I am 20 years old and I have been contemplating getting a breast reduction ever since I was in high school. I currently am 5'3'', 160 lbs, and a 36DDD. I have been working out and losing weight (-12lbs), but my large breasts are always an obstacle for me and burden on my back. Regardless of my weight, I know that these breasts are not meant for my small frame. Would the cost of getting a breast reduction be covered by my insurance (CalOptima)?

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

Randal Haworth, MD, FACS · Answer

With today's insurance plans under the ACA, less and less insurance companies cover breast reduction surgery despite that 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.

John D. Smoot, MD · Answer

Thank you for your question and is sounds like you are a candidate for this procedure.  There are several aspects of this procedure you need to consider before doing this.  You may not have finished growing and you may grow larger, do you want to have children and have the ability to nurse and how disruptive is this problem to your every day life?  I would find a board certified plastic surgeon who help you decide if this is right for you and guide you through the process.  Every insurance company is different in what they will cover and speaking with you surgeon and insurance company will determine if this is covered.

Arian Mowlavi, MD, FACS (license on probation) · Answer

Cal optima does in fact cover breast reduction. A consultation with a board certified plastic surgeon will be able to walk you through the steps requried to get authorization for your surgery.

Frederic H. Corbin, MD (license restricted) · Answer

Thank you for the question and that would be determined  after a consultation and your surgeon  attempting to get authorization.  So be evaluated in person and begin the processDr Corbin

Breast reduction & CalOptima insurance?

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Answer: Breast reduction candidate through Cal Optima

Answer: Breast reduction candidate through Cal Optima

Answer: Breast reduction

Answer: Breast reduction

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Breast reduction & CalOptima insurance?

Answers (5)

Answer: Breast reduction candidate through Cal Optima

Answer: Breast reduction candidate through Cal Optima

Answer: Breast reduction

Answer: Breast reduction

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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.