How Do I Begin The Breast Reduction Process? (With Wanting Insurance to Cover the Procedure)

I am 20 years old and I am a J cup. I have the WORST pain in my back, neck, and shoulders. I desperately need a reduction however I would need for my insurance to cover it. How do I begin? I have an appt with my new PCP but that's not until Nov. 4th. Do I HAVE to go to a PCP and have them refer me to a plastic surgeon ? Or can I start by going directly to the plastic surgeon myself? And which doctor is the one that should write my insurance company? Any and all info is welcomed and appreciated.

Doctor Answers 5

Breast Reduction Process paid by Health Insurance

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Typically your PCP has to refer you to the specialist. They're the "gate keepers". Once referred, then ensure your plastic surgeon is well respected for this procedure. Many plastic surgeons no longer accept insurance for Breast Reduction surgery because of the poor re-imbursement given now a days. Sometimes patients prefer to pay out of pocket, there by allowing them to pick their plastic surgeon. Insurance plans force you to use the doctors on their plan... which may not be your choice. 

How Do I Begin The Breast Reduction Process? (With Wanting Insurance to Cover the Procedure)

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Based on your description you may be an excellent candidate for breast reduction surgery.   

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. Make sure you are  consulting with a well-trained/experienced board-certified plastic surgeons.

When dealing with health insurance companies, be prepared to be persistent. Keep in mind, that breast reduction surgery tends to be one of the most patient pleasing operations performed.

Best wishes.

Breast Reduction and Insurance

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Contact your insurance to find out if you need a referral or if you can go directly to a plastic surgeon. Each insurance company has their own requirements as far as getting approval. Some will want you to have tried various methods for relief before approving surgery, such as physical therapy, good support bras, analgesics, etc. and they will want documentation of what you have tried. See a Board Certified Plastic Surgeon that specializes in breast surgery to help you go through the process of getting approval. If you should get denied, ask your surgeon to appeal your case, I have gotten many patients approved this way. Good luck!

Insurance breast reduction

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I'm sorry to hear that your large breasts have been causing you physical discomfort.  Your first step should be to contact your health insurance company about their coverage for breast reduction surgery.  Each insurance company is different and has its own specific requirements.  They can also tell you whether or not a referral is necessary and which plastic surgeons in your area are covered under your plan.  It is a good idea to meet with your PCP.  Most insurance plans require it.  Your primary care physician will document your symptoms and check for physical findings like shoulder grooves and/or skin infections under your breasts.  They can also examine your breasts and make sure there is no underlying medical problem leading to your overly large breasts.  Most insurance companies require you to try non-surgical measures like physical therapy and non-steroid pain medications before they will consider covering plastic surgery and your PCP can help with that.  Your PCP can also make sure that you are a good surgical candidate.  Assuming you are still having discomfort after trying the conservative therapy, your plastic surgeon would submit the insurance pre-authorization letter.  Best of luck to you!

Insurance may dictate things

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Whether or not you need a referral to see a specialist is determined by your insurance policy.Many these days do not require a referral but be sure to check your specific policy to be sure. The plastic surgeon would be the one to write the letter to the insurance company,but it is always helpful if you have letters from PCP,OB/Gyn or others you have seen for the symptoms. This procedure has  very high patient satisfaction,but be sure you follow the policy guidelines to have it covered.

C. Russell Sparenberg, MD
Plano Plastic Surgeon

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.