What Are the Steps to Getting a Breast Reduction Approved by my Insurance?

Question

Age: 20 Height: 5'2 1/2" Weight: 120 lbs. Bra size: 32 H I experience a lot of back pain especially in my shoulders. My bra straps often dig into my shoulders. I often feel pulling on my chest area because they are so heavy. I am concerned as to what size they would take them down to, what scarring there could be, what complications could occur, and what my experience would be post-op. I am also a recovering addict so pain medication is something I would have to refuse post-op.

Tom J. Pousti, MD · Answer

Based on your description you may be a good candidate for breast reduction surgery; this operation is one of the most patient pleasing operations we perform. 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.

	Before undergoing the breast reduction procedure it will be very important to communicate your size goals with your surgeon.  Most patients wish to achieve  enough of a reduction to help with their symptoms while remaining proportionate with the remainder of their torso. 
	With the goal of improving communication with my patients I find the use of photographs of “goal” pictures (and breasts that are too big or too small)  very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" means different things to different people and therefore prove unhelpful.  Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.

	In regards to postoperative pain management, your plastic surgeon will  likely be able to help with the use of nonnarcotic medications (as much is possible).

	 I hope this helps.

Kevin Tehrani, MD, FACS · Answer

You should have a consultation with a board certified plastic surgeon.  After He/She has examined you and established medical necessity, your insurance company is contacted for preauthorization.  Discussions of risks and benefits of surgery including postoperative size needs to be done in person with your surgeon.  Best of luck.

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

Sugene Kim, MD, FACS · Answer

Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.

William B. Rosenblatt, MD · Answer

See a plastic surgeon -- talk to them , they should take photos and then you can contact your insurance company with them. If you have consults from internist showing back pains it might help. The insurance companies are becoming more difficult.

What Are the Steps to Getting a Breast Reduction Approved by my Insurance?

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What Are the Steps to Getting a Breast Reduction Approved by my Insurance?

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