How do I get insurance approval for a breast reduction? I don't want to wait 6 months while I do physical therapy.

Question

I am 18 years old and am a 30 DDDD bra size. I am 5' 1'' and weigh 130 pounds. I am frustrated that I need to go through 6 months of physical therapy. I am in college and I don't have a car on campus so I can't do the physical therapy. Is there a way to get around that I need the surgery. when I was 14 I had surgery to remove a tumor from my right breast. I have severe back pain and lately I have been getting depressed because I can't exercise.

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems you are experiencing secondary to breast hypertrophy; based on your description you may be an excellent candidate for breast reduction surgery at some point.   “Official” recommendations of course would necessitate in-person consultation.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 (in other words, the breasts are "automatically" lifted when a breast reduction is performed). 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. Obtaining insurance coverage for breast reduction surgery will likelyinvolves 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 letters/pictures from your plastic surgeon will help you obtain authorization.  Prepare to be persistent when dealing with health insurance companies.When the time is right,  seek consultation with well-trained/experienced board-certified plastic surgeons. Ask to see lots of examples of their work and communicate your goals clearly.I hope this, and the attached link, helps.  Best wishes as you work towards your goals.

Vincent N. Zubowicz, MD · Answer

If your insurance mandates physical therapy there's not much you can do about it. However check with your plastic surgeon  as many insurance companies don't require this. It's  a bizarre requirement considering physical therapy will not make the breasts any smaller.

Bram Kaufman, MD · Answer

It looks like you have a good case to make to your insurance company.  The criteria and process that insurance companies use to determine eligibility don't always work for every individual. In our practice a routine workup includes a history, physical exam, and photographs which are all submitted to insurance. It is the complete set of data that should be used to make the decision. For example, a good candidate is one who suffers from pain, rashes, shoulder grooving from the bra, is not overweight and has findings on physical exam that confirm the chronic effects of large breasts. Even with physical therapy, those issues (except for possibly back pain to some degree) will not improve. It is best to submit for insurance preauthorization with additional emphasis on the signs and symptoms you are suffering from that will improve with surgery above and beyond your back pain. A photograph is often the key piece of information along with a letter from your surgeon explaining your particular situation. Ultimately, a peer to peer review between your doctor and the insurance comparny may be necessary. I hope this helps.

Farah Naz Khan, MD · Answer

Not sure why you need physical therapy unless that is a stipulation of your insurance policy. Unfortunately, every insurance company and even plan has a different set of criteria to approve breast reductions and even then, some reductions do not get approved. Best to talk to your insurance company to see if there are any exceptions if they do require a period of physical therapy before surgery. Also, it would be good for you to go see a board certified plastic surgeon so they can take photos and start gathering the medical information needed to submit on your behalf. Good luck!

Steven Wallach, MD · Answer

I think that the best thing for you to do first, is to check with your insurance company to determine what their criteria are for approval.

How do I get insurance approval for a breast reduction? I don't want to wait 6 months while I do physical therapy.

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Answer: How do I get insurance approval for a breast reduction?

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Answer: Breast reduction and insurance

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How do I get insurance approval for a breast reduction? I don't want to wait 6 months while I do physical therapy.

Answers (7)

Answer: How do I get insurance approval for a breast reduction?

Answer: How do I get insurance approval for a breast reduction?

Answer: Breast reduction and insurance

Answer: Breast reduction and insurance

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Recommended reading

Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.