Will Tricare Cover a Breast Reduction for Me?

Question

I have appointment for back pain with my primary care provider. I plan to ask for a breast reduction referral. I am 22, have an 18 month old child and have always had large breasts. They became bigger with pregnancy, I am now a 34 E or f, (my left breast is at least a cup size larger than the right) I am 5'4 and weight 150 pounds. I've lost 45 pounds since birth with no change in my breasts. I have severe neck and back pain, my fingers get tingly, and I am just so uncomfortable!!

Randy Proffitt, MD · Answer

Different insurance companies have different criteria for covering breast reduction. You seem to have all the qualifications to have the surgery, but what a plastic surgeon thinks and what the insurance criteria is may be totally different. The more documentation you have that it is "medically necessary" and that you have tried all the conservative measures without success helps your case. Usually a minimum weight to be removed is required. Sometimes it is an absolute amount or it may be based on the "Schnur scale" according to your height and weight. Conservative measures are support bras, physical therapy, ruling out intrinsic causes of back pain, medications for skin rash. You may also want to have nerve conduction studies to see if the tingling in your fingers is related. Ultimately you will need a letter and photos from a plastic surgeon and accompanying supporting documents to see if you qualify.

Tom J. Pousti, MD · Answer

Thank you for the question.
	Based on your description, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations we perform. 
	You will need to check with your insurance company directly to see whether your policy covers this operation. They will also be able to tell you whether you will have any direct responsibility/expenses if you choose to undergo this procedure.
	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. When dealing with health insurance companies, prepare to be persistent…
	 I hope this helps.

William B. Rosenblatt, MD · Answer

It's your insurance, we have no idea if it will or will not cover --- call them. In my exprience, insurance is now paying less and less - and does not cover really necessesary surgery. Good luck with them.

Jeffrey Thaxton, MD FACS · Answer

Based on your symptoms you would be a candidate. Height and weight likely also OK. Cup size also likely to make you a candidate. Ultimately you would need an evalualtion by a board certified plastic surgeon and get an estimate of the amount of breast tissue that would be reasonable to remove to find out if you would qualify.

Will Tricare Cover a Breast Reduction for Me?

Answers (4)

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