What's the Likelihood of HMO Illinois Covering 34DD Breast Reduction?

Hi! I'm 5'3", 135 lbs (lots of muscle) with 34DDs, and I want a reduction. I have trouble with my breasts (back/shoulder pain), but especially while running. Breathing is very difficult since I already have asthma, and the sports bras I have to wear + back tightness makes things awful. I'm wondering if these criteria are 'enough' to get approved, or if anyone knew the HMO Illinois systems particular regulations? What size would an insurance-approved reduction bring me down to? Thanks!

Doctor Answers 8

HMO coverage for breast reduction

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HMO Illinois has a very good record for coverage for breast reduction, better than the PPO plan in our area. If your primary supports the referral the chances are very good that the plan will allow breast reduction.

Best of luck,


Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Breast Reduction Insurance Coverage?

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Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.

Based on your description you may be a good candidate for breast reduction surgery; for  physical and emotional reasons.
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're  working with a well-trained/experienced board-certified plastic surgeon.

Best wishes.

Will my insurance approve my breast reduction?

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In order to approve a breast reduction, insurances will look at medical records supporting symptoms of back pain, neck pain, shoulder grroving, shoulder pain, and recurrent skin rashes. It is very importatn to have these symptoms well documented by your primary care physician who should then refer you to a board certified plastic surgeon who is a provider for your insurance. The plastic surgeon will then submit the documentation, photos, measurements, and a letter of medical necessity. Ususally, at least 500 grams of breast tissue have to be removed from each breast for approval.

What's the Likelihood of HMO Illinois Covering 34DD Breast Reduction?

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You need to see in plan boarded PS in that HMO. He than can write a letter of predetermination to the HMO with your photos to obtain an OK. Each insurance company has their own citeria for approving breast reduction as a covered benefit. It is a "process". Best of luck

Insurance coverage for breast reduction.

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Insurance Coverage for Breast Reduction

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Obtaining coverage for breast reduction surgery from insurance company

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As Dr. Marosan noted, you need to ascertain whether your particular insurance plan does cover breast reduction surgery. If it does, you should seek a consultation from a board certified plastic surgeon in your area who could examine you and determine whether it would be likely that you may be able to obtain approval for insurance coverage of the procedure. He/she could also then submit your information.

Your symptoms are helpful in fulfilling criteria for coverage. Often, a certain amount of breast tissue will need to be removed as well and this is based on your height and weight.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
4.7 out of 5 stars 33 reviews

Insurance criteria for Breast Reduction surgery

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Most insurance companies require at least 500g per breast to be removed which approximately corresponds to 2.5 cup sizes. This may be too small for your frame. What I usually recommend is for patients like you who are not that large to finance the reductions themselves so that you are not unhappy with your results. Another point I'd like to emphasize is that there is a new technique for reducing breasts that not only makes them smaller, but the weight of the breast mound is transferred to the muscles of your chest wall. This provides internal support to immediately relieve pain. Standard breast reduction techniques do not do this, they only rely on the skin envelope for support. Permanently attaching the weight of the breast to the chest muscles also minimizes downward displacement of the breast mound. An added benefit to this new technique is that scarring has been minimized. There is NO VERTICAL SCAR regardless of how large or saggy your breasts are.

Best wishes

Dr. H 

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Insurance coverage for breast reduction

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You need to look at your contract with the HMO or call them to see if btreast reduction is one of the surgeries they cover and what are their criteria if symptoms, weight removal and or second opinion requirement for an orthopedic evaluation, physical therapy and so on. Insurance co. place more and more restrictions so more people will get discouraged with the process. Good luck.

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.