Do you have any tips for getting insurance to approve a breast reduction?

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.  

Thank you for your question.
Make sure you have documentation supporting a necessity for a breast reduction. Shoulder grooving, neck/back pain, etc. Family physician and gynecologist can help out with this. Best wishes!

When seeking insurance approval for a breast reduction, it's essential to be proactive and well-informed, as each insurance plan has its own specific criteria for coverage. Typically, insurance companies require documented evidence of symptomatic macromastia.
*What is symptomatic macromastia?* This condition often results in symptoms such as chronic back, neck, and shoulder pain, skin rashes or irritation underneath the breasts, difficulty finding well-fitting clothing or bras, and limitations in physical activity. Women with symptomatic macromastia may experience significant emotional distress due to the physical discomfort and the impact on their daily lives. In many cases, breast reduction surgery is considered a treatment option to alleviate these symptoms by removing excess tissue, reducing breast size, and improving both physical comfort and overall quality of life. Insurance providers may cover the surgery if it is deemed medically necessary, based on the presence of these symptoms and other documented factors.
*What needs to be documented?* Providers need to build a strong case for medical necessity. This means documentation of failure of conservative treatments, such as weight loss, physical therapy, pain management, and medication for symptoms like neck, back, or shoulder pain. In addition, many plans require a certain amount of tissue removal (usually based on the Schnur Scale which considers body weight, body mass index, body surface area), although this can vary depending on the insurer. It’s important to work closely with your primary care doctor, who can document your attempts at non-surgical treatments and provide a referral for physical therapy, if applicable.
*What’s next?*You should consult with a plastic surgeon who specializes in breast reduction. The surgeon will assess your condition and measure the amount of excess tissue, which is important when submitting to insurance. Often, the surgeon will also provide supporting letters, detailing your symptoms and the need for surgery. It’s also a good idea to gather additional supporting letters from other healthcare providers, such as a physical therapist. By carefully following these steps and ensuring all documentation is thorough, you will maximize your chances of obtaining insurance approval for the procedure.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

In Australia, this procedure is often deemed medically necessary, and therefore there is an associated Medicare item number. Therefore, private insurance rebates will apply, assisting with the overall costs. The main contribution will be towards the hospital fee. However, the total price you pay even with insurance will depend on the specifics of the surgery. This is because we cater each operation to the patient.

Great question and I mimic what Dr. Hammoudeh said.  The key is to document (have receipts or photos) every medication or powder/cream you may have purchased if you have rashes under your breasts.  Document or obtain any office notes from your PCP indicating issues with shoulder grooving, back and neck pain.  Some insurance carriers also want proof that you tried dieting and exercise to reduce the weight of your breasts for a certain period of time (ie. 3-6 months). All this and they will still require a letter of necessity from your doctors and photographs.  Not to mention they require a weight of tissue removed during surgery which may not be either feasible or what you inevitably desire as your overall size.  Given that there are so many moving parts, consulting with a plastic surgeon is best to determine your goals, expectations and likelihood that your reduction will be covered for insurance.  Oh, and hearing back on whether the insurance company covers the procedure could take several weeks to a few months, so timing your surgery and consultation around your schedule is key.  Hope that helps!

Hi and thanks for your question.  Every insurance plan has its own specific criteria for what they consider medically necessary in regards to a breast reduction, despite what your doctor’s opinion may be.  It’s the patient’s responsibility to be proactive and contact their own plan in advance so that they can be familiar with these criteria and provide their doctor with the relevant information (for example, if you’ve been treated by a physical therapist, or if you been prescribed medication for rashes).  Don’t expect your doctor to know the details of what your specific individual plan considers medical necessary, your doctor can provide their medical opinion but ultimately the insurance company decides if they agree — every plan is different and has its own rules.  If you want to get your insurance involved stay ahead of the game and find out their specific requirements in advance by contacting them yourself.  That way there’s no surprises.A visit to a plastic surgeon's office will help you to understand if you're a candidate for the procedure, and what aesthetic outcomes are realistic in your particular case.  In order to get a qualified, ethical, and expert opinion on your surgical options and expectations, always schedule an in-person office consultation with a plastic surgeon certified by the American Board of Plastic Surgery.
Best of luck,
Keith M. Blechman, MD
New York, NY

Insurance companies look at may factors when determining whether to approve your reduction or not.  They will often look at things like your BMI, breast measurements, and photos.  They will also want to know if you suffer from symptoms due to large breast size such as back pain, neck pain, or rashes beneath the breasts and what type of conservative measures you have tried to address these symptoms.  Even with all of this information, unforturnaly some insuance companies still will not approve. 

Dear Madam Squeak,
My first recommendation from a safety standpoint is to get your BMI 30 or under prior to your surgery.  Your operation will likely be more successful... with better results, less chance of a complication and faster recovery. So a weight of approximately 192 or less would be ideal.  As for getting insurance authorization (aside from the weight loss)... it would be beneficial to get documentation from your primary care physician about symptoms from your large breast like persistent neck or back pain. Hope this helps!

Breast reduction is a surgical procedure designed to reduce the amount of breast tissue. Reduction is recommended for women that experience a significant amount of discomfort due to the weight and size of their breasts (shoulder, back, neck pain). They may have difficulty exercising or wearing certain types of clothing. During surgery, excess skin, fat and breast tissue may be removed as well to improve sagging. The sagging nipple position is corrected and the breast is reshaped. The incision is typically made around the nipple, extending vertically down to the crease, and then ending in a horizontal line within the breast crease (similar to the aforementioned mastopexy). While this operation is technically similar to a mastopexy, it is performed for a very different reason.
With regards to your specific question, creating a case for medical necessity is crucial. Most insurance providers will want evidence of 3 failed prior interventions. They will often request a Schnur score (measure of Body Surface Area) in order to determine the necessary required resection.Prior to considering surgery you should consider alternatives which can help with the symptomatology associated with excess breast tissue. This can include weight loss, physical therapy, and medical therapy (for pain). This should be documented by your primary care physician as this will be important from an insurance perspective in creating a case for medical necessity. Documentation is crucial.
Once you have decided to proceed, seek out a board certified plastic surgeon (ABPS) to discuss your options. The ideal candidate is otherwise healthy, has reached a stable weight (preferably with a BMI

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.

Thank you for your question.  I see many patients in consultation each week who are interested in having a breast reduction covered by their insurance and unfortunately it is difficult to predict exactly which patients will have success in their insurance considering it a covered benefit and which patients will not.  Each insurance plan has their own specific criteria that must be met to deem a breast reduction as medically necessary.  This criteria often includes: failure of alternative treatments, a minimum required amount of tissue to be removed (usually at least 500g per side), BMI, extensive documentation of back, neck and shoulder pain, extensive documentation of inframammary rashes, etc...  To help strengthen ones case for medical coverage, my office will often attempt to obtain documentation in the form of letters of medical necessity from primary care physicians, orthopedic surgeons, chiropractors, physical therapists, and/or dermatologists who have treated the patient in question.  These letters attest to the relationship between the patients large breasts and specific symptoms, and go on to state that these symptoms would be relieved from a breast reduction procedure.  If you are interested in having a breast reduction, I would recommend scheduling a consultation with a board certified plastic surgeon who is well-experienced in these procedures.  At the time of your consultation your options can be thoroughly reviewed and your candidacy for a breast reduction can be best determined.  As a necessary first step in attempting to obtain medical coverage for this procedure, your consultation and physical exam will provide great insight as to what predetermined criteria you may already meet and what your chances are in obtaining insurance approval.  I hope you find this helpful and I wish you all of the best!