Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance. I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well). Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the large breasts. Supporting documentation is usually very helpful. Insurance companies are getting more strict and probably going from DD to D may not fall within the limits to go through insurance. If it bothers you enough, you may want to consider paying for that surgery.
Will Insurance Pay for a Reduction rom 36DD to 36D?
Doctor Answers 9
Breast Reduction covered by insurance?
Insurance coverage for one cup size reduction
Insurance companies typically use formulas utilizing your height and weight to determine the amount (or weight) of breast tissue that must be removed from each breast in order for it to be "medically necessary". Usually, they won't approve a breast reduction that is not at least 2 or more cup sizes.
Will Insurance Pay for a Reduction rom 36DD to 36D?
Your health insurance company has minimum guidelines in breast reductions as for amount of weight to height needed to be removed. Most use the "magic" number in grams at 500 gms per side. You need to check with your carrier what that weight per side is. Sounds to me you desire a lift more than a reduction, so I believe you will be denied.
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Question about insurance coverage for breast reduction
Insurance coverage for a breast reduction in general is fairly difficult/time consuming to obtain and many insurance companies have very stringent criteria including specific weights of tissue that need to be removed for a given height, documentation of symptoms, having specific lengths of therapy which have failed to alleviate symptoms, etc. Others even have a specific exclusion of coverage.
Going down only 1 cup size will not fulfill the minimum weight criteria of removed tissue in order to get authorization for coverage. You still could have the procedure performed but you would be paying the full costs.
To more appropriately confirm this, you should be evaluated by a plastic surgeon in your area.
Insurance approval for breast reduction surgery
The only way to know if your breast reduction would be a covered insurance is to have a plastic surgical consultation. Once examined, a plastic surgeon would be able to determine if you meet insurance requirements. These requirements can vary widely.
Insurance coverage for breast reduction.
Insurance Coverage for Breast Reduction
Article 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.
Insurance Unlikely To Cover One Cup Size Reduction
Your insurance company is not likely to cover the costs of a reduction mammoplasty involving reduction of a single cup size. Although there is a wide variance in requirements among different insurers, all require certain symptoms to be present as well as the removal of a specific weight of breast tissue. Many also require a trial of "conservative therapy" (PT, etc.) which virtually never corrects the pain associated with true mammary hypertrophy. Obtain a consultation with a board-certified plastic surgeon with whom you can discuss your options.
Breast reduction insurance coverage
Your insurance company will require a certain amount of weight to be reduced from each breast to qualify as a breast reduction. The final bra size is not important to the insurance company because they are in the business to help your symptoms and not your appearance. To make the small change from a D to DD will probably not fit the criteria of most insurance companies. If your symptoms are bad enough you might be happier with smaller breasts. Discuss this with your plastic surgeon as well as your insurance company.
Insurable breast reduction
Insurance for breast reduction is based on tissue weight removed, not on cup size. The other factor is your body surface area and the guidelines and policies of your insurance as they are all different from company to company. The likelihood would not be that they would cover a change from a DD to a D. This would be considered cosmetic probably.
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.