How Do I Know if I Will Qualify for a Breast Reduction? (photo)

I'm 36yo currently a 34J. I have the shoulder grooves, constant back pain, skin irritation, and headaches. I am 63in tall and 175lbs. My adult weight has been right around 170 much of my life. We are done with children, so no more breastfeeding. I am very done with the back pain. By my own measurements notch to nipple is 32cm and IMF to nipple is 17cm. My consult isn't until May 8th and I fear I will be told my breasts aren't large enough for the minimum resection. Are my fears irrational?

Doctor Answers 7

Breast reduction

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I think there are two issues here- as to whether or not your insurance will pay for your reduction, it really depends on your insurance plan and so giving you an opinion about that is going to be really difficult on the internet.  The other issue is that you are without question and excellent candidate for a breast reduction.  I certainly hope your insurance can do the right thing, but know that a reduction will significantly improve your comfort as well as appearance- best of luck!

Breast Reduction Candidate?

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Thank you for the question. I'm sorry to hear about the physical and probably psychosocial problems your breasts have caused.

Breast reduction surgery is one of the most patient pleasing operations we perform. By removing “excess” breast tissue, adipose tissue, and breast skin  this operation reduces and lifts the breasts to a higher position on the chest wall. By doing so, patients often find improvement in neck, back, and shoulder discomfort and find it easier to form their activities of daily living and exercise.

Timing of the operation will depend on the patient's life circumstances. In general, it is best to do this procedure ( like all other elective body contouring the stages,  when patients have reached their long-term stable weights.  In doing so, improve the safety of the procedure and minimizes the need for further surgery ( in the event of weight gain/loss after the breast reduction procedure).

Whether or not the breast reduction procedure is covered by your insurance company will depend on the specific insurance company and your policy. You will need to check with them directly.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.  Prepare to be persistent when dealing with insurance companies and the authorization process.
Best wishes.

How Do I Know if I Will Qualify for a Breast Reduction?

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I think you are asking about health insurance coverage for your breast reduction. It depends upon the type/plan of the insurance company. At your consult ask if your are covered. Your PS will contact the health insurance company with your info and photos to see. 

How Do I Know if I Will Qualify for a Breast Reduction?

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Thank you for the detailed information and measurements.  Insurance company guidelines have changed dramatically over the past 25 years that I have been in practice.  It used to be that the weight of the breast tissue removed determined whether you qualified for insurance coverage.  But now, most insurance companies require different variations of a 6-month period of "conservative management (whatever that is!)", and sometimes a letter of necessity from an orthopedist or (believe it or not) a chiropractor!  So it all depends on your insurance company and their guidelines.

Ruben B. Abrams, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 19 reviews

How Do I Know if I Will Qualify for a Breast Reduction?

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It looks like you should qualify easily, but insurance companies are pretty unpredictable. The only way to really be sure is to see a surgeon and after the consultation his office will communicate with your insurance carrier and within a few days they should have an answer for you. BTW, I can't think of a single breast reduction patient after 30 years of doing the operation, that wasn't thrilled. So I am sure all your work and worry will be rewarded.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 reviews

Will insurance cover my breast reduction?

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  • Looking at your photos, it is likely that you would qualify for a breast reduction based on the amount of tissue that would be removed.
  • However, insurance companies often look at other criteria such as pain, rashes, and any therapy that you may have tried to alleviate these issues.
  • It is definitely worth your time to be evaluated by a plastic surgeon to see if you'd qualify.  Insurance companies usually require a letter from a plastic surgeon, chart notes, and photographs.
  • Best of luck to you!

Qualifying for Breast Reduction

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You are most likely a good candidate for breast reduction surgery. Each insurance company sets its own requirements, but most stipulate that a minimum of 500 grams of breast tissue needs to be removed from each breast, and that usually equates to a DD cup minimum. Still the insurance company will want documentation of what you have tried, such as good supportive bras, physical therapy, analgesics etc. Again, insurance companies have their own requirements, if for any reason you should get denied, ask your surgeon to file an appeal, then a medical doctor representing the insurance company will contact your surgeon to discuss your case. I have gotten several approved this way. Good luck!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 81 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.