Where to Start with Insurance Coverage?

Where should I start if I want to get breast reduction covered by insurance? I'm 30 years old, 134 pounds and 34DD. I have always had headaches and backache due to my breasts.

Doctor Answers 5

Insurance Criteria for Breast Reduction Varies between Companies

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Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria. Here is some general information however to help you :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 though insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Insurance Coverage

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The first step is to see if your insurance company's requirements for coverage is online. If not, a call to the insurance company to get an understanding of requirements is useful. Consult with a board certified plastic surgeon to verify that you are a candidate for a breast reduction and to ensure that you fall within the requirements of your plan. At some point, it is useful to get independent verification that the surgery is medically necessary. You can either meet with your primary care doctor, physical therapist, chiropractor etc. either before or after you meet with the board certified plastic surgeon to get this independent verification.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 56 reviews

Get a consult first

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It would be nice if insurance companies posted their info on line, but most don't. See a board certified plastic surgeon first and go from there.

William B. Rosenblatt, MD
New York Plastic Surgeon
4.2 out of 5 stars 12 reviews

Breast Reduction and Insurance Coverage?

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Thank you for the question.

Based on the description of your body type and symptoms, you may be an excellent candidate for breast reduction surgery.  I think the best place to start would be with in person consultation with board-certified plastic surgeons.

A phone call to your insurance company will also be helpful.The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. 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.

This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.  Prepare to be persistent when dealing with insurance companies and the authorization process.
Best wishes.

Beginning with insurance coverage

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Now that so much information is on the internet, I recommend beginning online. Your insurance company's criteria for breast reduction should be posted online so read and review them. This will give you a starting point. If your insurer expects documented medical management, the types of management (pain medication, orthopedic treatment, physical therapy, etc.) will be spelled out in the alternative and also the number of months of treatment required will be made clear. Once you understand the criteria, but before spending all that co-pay money on physical therapy, I recommend seeing a board certified plastic surgeon in consultation. Given your bra size, you need to know based on the gram weight requirements set by your insurance carrier, how much needs to be removed from each breast. If you find that the minimum amount is too much for you and will make you too small, it is much better to know this in advance. Your insurer may also require documented complaints; you may well have complained to your primary care physician or gynecologist for years about your breast size but if it isn't in your medical records, unfortunately, the insurance company will not credit you for those complaints. Best of luck as you begin to pursue this surgery.

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.