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 22

Insurance coverage for breast reduction.

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
4.8 out of 5 stars 9 reviews

Ask Your Plastic Surgeon to PreApprove your 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.  

Insurance Coverage

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

Insurance coverage for breast reduction

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.

Breast reduction: insurance coverage

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
5.0 out of 5 stars 90 reviews

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

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.

The 5 Most Important Factors in Getting Insurance Coverage for Breast Reduction

Insurance carriers have become much more demanding prior to approving coverage for the Breast Reduction Procedure:  Over a 30 year career we have found the the most important factors in obtaining coverage are: 
  • History: long standing history of multiple symptoms associated with this condition:  Bra strap irritation, back problems, neck strain, rashes beneath breast and most importantly a diminished overall activity level. A letter from the patients medical doctor documenting the symptoms is also extremely helpful. 
  • A well documented attempt at improving the above noted symptoms for at least one year.. including: Treatment of rashes beneath breast, physical Therapy for back problems, medication: muscle relaxers, mild pain pills (tylenol)
  • Physical Examination: the weight is extremely important and if you are over-weight your chances of being covered are drastically diminished. Bra Size: Chest wall measurement and the anticipation of the amount of tissue to be removed from each breast by the examining physician. 
  • A prior authorization letter is then sent to the insurance carrier with documentation of all of the above findings with photographs included. 
  • We have our patients fill out their forms with the above information prior to their consultation and most patients will receive a response from the insurance carrier within 2 to 6 weeks. 
Good Luck

Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
4.3 out of 5 stars 11 reviews

Will my insurance help cover the cost of surgery?

Thank you for your question. Insurance coverage is sometimes available for breast reduction surgery. Many factors determine your eligibility, including the specific terms of your insurance policy and the amount of breast tissue to be removed. A letter of predetermination may be required by your insurance company prior to surgery. Unfortunately, at this time, the doctor does not accept insurance reimbursement for this type of surgery. Our office will be happy to assist you in getting reimbursed by providing any necessary information to you such as ICD and CPT codes and copies of your records. We do not correspond with the insurance companies for you. Best of luck!

Dhaval M. Patel 
Double board certified
Plastic surgeon
Hoffman Estates 
Barrington
Oakbrook
Chicago 

Dhaval M. Patel, MD
Hoffman Estates Plastic Surgeon
4.9 out of 5 stars 70 reviews

Insurance

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
4.8 out of 5 stars 11 reviews

Insurance

Breast reduction, or reduction mammaplasty patients are among the most satisfied of all plastic surgery patients. Large breasts (macromastia) can often decrease quality of life for a woman. With breast reduction, you can have smaller breasts that sit higher on your chest wall. You will also find relief in your neck and back with the decrease in weight and more ergonomic position of your breasts.
There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.
1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.
2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.
3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.
Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.
The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!

Sheila S. Nazarian, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 43 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.