Tips for Getting Insurance to Approve Breast Reduction?

I am 5'7" and last weighed at 210lbs, yes I know I am over weight. My bust is 40 H. I have been working out at my apartment's gym for a few weeks now. I have lost some fat and gained some muscle, and after losing some weight I gained it back without gaining the fat back (so in other words it is muscle) my natural waist is measured (this morning actually) at 34" and my bust is measured at 48", but all my doctor is concerned about is my weight. not my true body fat percentage. Any tips on how I could get my insurance approve my breast reduction?

Doctor Answers 29

Insurance coverage for breast reduction.

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Insurance Coverage for Breast Reduction

Answer by. George J. Beraka, MD
Manhattan Plastic Surgeon
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.


Manhattan Plastic Surgeon

Ask Your Plastic Surgeon to PreApprove your Reduction.

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Most insurance companies don't factor in muscle mass.  
Most use some variation of the Schnurr formula which calculates your BSA body surface area, and then each company has a certain number of grams required. 

In many ways, this is fair to most.  Little tiny women have a smaller grams requirement than big women, but it is somewhat proportional. 

Ask your plastic surgeon to seek pre-approval for your breast reduction. Most are approved. For the few that are not, you can calculate how much weight you might need to lose to get approval, or with some plans, you might find the requirements too strict.  In some cases, it may make sense to seek a cosmetic, or cash pay rate.  

Insurance coverage for breast reduction

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If you have H cup breasts and your insurance company considers this gigantomastia, rather than macromastia, the weight will not be an impediment to insurance approval. Every insurance company has different criteria. If your chest circumference is 48, then you may not be a 40H cup, but could be a 48 with a smaller cup size. For many insurers, the photograph will say it all. Additionally, each company has its own set of criteria. Some will require a prescribed body mass index. Others look for conservative medical management, such a chiropractic, pain medication, physical therapy, neurology, etc. prior to approving surgery. Become an educated insured and look up your carrier's requirements online. Then see a board certified plastic surgeon in consultation who knows how to navigate the insurance system and will advocate on your behalf.

Insurance

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Each insurance plan has their own criteria for when they will pay for a medically necessary breast reduction.  Insurance plans are becoming more scrutinous of this procedure.  Typically, they seem to want to see truly large breasts that are ALSO causing or exacerbating musculoskeletal strain symptoms.  They also typically want to see a patient that doesn't have another major reason for those symptoms, such as obesity, and also want to see a reasonable trial of conservative measures to manage those symptoms.  The patient must also be willing to have substantially smaller breasts (not just a lift).  For the average woman, this seems to be at least 500 grams of breast tissue removed per side, although smaller amounts may sometimes be approved--some third party payor utilize BMI- based formulas.  That said, I've often found that women with truly huge breasts are often going to be approved, regardless of their general fitness level, on the basis of a photograph and a letter from their plastic surgeon.  It is definitely worth a consultation to see a plastic surgeon who has a lot of experience with this procedure; they will be able to steer you in the right direction.

Jeffrey D. Wagner, MD
Indianapolis Plastic Surgeon
4.9 out of 5 stars 30 reviews

Breast reduction: insurance coverage

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breast reduction: insurance coverage
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.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

Insurance Coverage

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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. Basu
Houston, TX

A Prior Authorization Letter From Your Plastic Surgeon Will Help to Get Your Breast Reduction Approved

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Breast Reduction is often considered medically necessary by insurance carriers and is therefore a covered expense.  Before approval can be granted insurance carriers require prior authorization.  This is a time consuming process that may take months.
The process begins with a consultation, followed by a prior authorization letter to the patient’s insurance carriers. This letter should include documentation of the patient’s history, symptomatology,  pertinent physical findings, attempted non surgical management and anticipated amounts of tissue to be removed.
Supporting pictures as well as documentation of conservative management are also very important.  This might include documentation of physical therapy, chiropractic care, the use of specialized support bras and non steroidal anti inflammatory agents.
The amount of tissue removed is one of the more important criteria used by insurance carriers.  This number varies from insurance carrier to insurance carrier.  Its often part of a height weight index.  As a patient’s weight increases insurance generally require the removal of more breast tissue.
In your case, it would be unlikely for your insurance company to deny prior authorization for breast reduction.  The size of your breast would meet most insurance company’s weight removal criteria, especially if you have appropriate supporting documentation.
If your considering breast reduction surgery, consultation with a board certified plastic surgeon who has experience in this area would be helpful in obtaining prior authorization for this procedure.

How to get Insurance to Pony up for breast reduction

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You sound like a good candidate based your symptoms and measurements, but coverage of the procedure varies widely from one insurance policy to the next. Many insurance companies will cover if you have 500 grams of excess breast tissue (about 1 lb) per side and rarely some may cover as low as 350 grams. However some companies may require a kilo or more.  This being said before you go forward with surgical procedures you may want to see your primary care physician to get a referral for physical therapy. Many neck and back pain symptoms can be treated very successfully with strengthening of the spinal supporting musculature.  This requires some time and effort but may provide a lifetime of benefit.  Insurance companies usually want to see a record of having been treated by nonsurgical methods for at least six months and not getting improvement with conservative treatments.  This usually means that you have tried diet and exercise, medications and possibly therapy or chiropractic and have not gotten adequate relief.  The next thing to do is get an exam with a board certified plastic surgeon with a good reputation. He should be able to perform an exam to tell exactly how much excess breast tissue you have.  Then the surgeon will write a letter to the insurance company and see if they will give approval for the surgery. The insurance company will send both you and your provider a letter with their decision within a few weeks in most cases.  Many patients are able to get insurance coverage for the procedure, but if you do not qualify many places offer a significant reduction in the price for out of pocket cases that are paid in advance.  Best of luck on your journey.

Jonathan Amspacher, MD
Kansas City Plastic Surgeon
5.0 out of 5 stars 14 reviews

Breast Reduction and Insurance

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Most insurance companies use the Shnur scale. This takes into account your Body Mass index and BSA or Body surface area. Based on this, the insurance company will determine how much breast tissue needs to be removed at a minimum in order to cover the procedure. In our practice, if I feel that the amount of breast tissue that needs to be removed is possible, then we proceed with surgery irrespective of what your BMI is. In some cases I have personally spoken to the insurance companies as an appeal to try to get the procedures covered. In does work in some instances. Letters from any other healthcare providers you have seen for your neck and back pain such as Primary care doctors, chiropracters, and rehab physicians can help immensely.

Best wishes,

Dr. Ravi Somayazula

Ravi Somayazula, DO
Houston Plastic Surgeon
4.8 out of 5 stars 71 reviews

Getting your breast reduction operation covered by insurance

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Dear Madam_Squeak,

Your surgeon is concerned about your weight for a good reason. There are two factors that most insurance companies look at when authorizing operations:

1.) Your symptoms, such as back, neck and/or shoulder pain, postural difficulties, skin problems between or under the breasts, and nerve compression manifested by numbness and tingling in certain fingers.  Furthermore, the treatments one has undergone to try to relieve these symptoms are also evaluated. The company wants to see that more conservative measures like physical therapy have been tried before approving an operation.

2.) This factor is what your surgeon is concerned with.  Before approving an operation, the insurance company's medical reviewer also wants to know how much breast tissue will be removed to determine whether this is cosmetic or functional by their definition.  The Schnur scale correlates an individual's body surface area (BSA) with kilograms of breast tissue to be removed.  Many companies use this scale to help them in making this determination.  So whether it is muscle or fat, your weight influences this number, the higher one's BSA, the more breast tissue needs to be removed to satisfy the insurance company's requirement.

Elysa Fisher, MD
Wilmette Plastic Surgeon
5.0 out of 5 stars 7 reviews

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.