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Will health insurance cover breast reduction?

Q:

I am 25 years old.  When I was 15, a surgeon approved me for a breast reduction but my mother declined it.  Now I am 25 and a mother of three and I have some changes in body size.  I have horrible neck and  back pain, and cannot go without wearing a bra.  I am a size DD pushing whatever would be the next size.  Due to the heaviness of my breasts, they hurt when I am not in a bra.  Do you think my doctor will advise/approve me to have a breast reduction and will my insurance company approve coverage for the procedure?

A:

You may well be a candidate for breast reduction surgery from what you describe.  

Whether or not insurance companies will cover your surgery varies greatly. Each has different criteria, many insist on a course of physical therapy first, they also require additional documentation and evaluation of your neck and back pain complaints as they may be due to other causes.

You should start first with your medical doctor and have an evaluation of your neck and back pain to exclude other possible causes beside heavy large breasts.  

Then you should consult with a board certified plastic surgeon about breast reduction surgery.  The risks, goals and alternatives will be discussed, as well as your insurance company's requirements for covering your surgery, such as the necessary amount of breast tissue to be removed, etc.

Fredrick A. Valauri, M.D. F.A.C.S.M.D., F.A.C.S.
New York, NY

A:

Hello Amanda,

From the information you have provided, it is likely that your doctor would recommend that you have breast reduction surgery.  It is also possible that he or she may want to rule out or treat other causes of your symptoms such as arthritis or generalized obesity.

Financial coverage for such surgery and the criteria that insurance companies use to determine it, vary widely from company to company.   Factors such as the presence of physical signs including bra strap grooving on your shoulders, or rashes beneath your breasts might be considered.   An estimate by your surgeon of the weight of the tissue that is to be removed from each breast or the actual weight of the tissue that is removed in an operation is often used in such decisions.   I am also aware that some companies or governmental agencies have insisted that patients either achieve, or try to achieve and maintain a normal body weight before authorizing financial coverage for such surgery.  

My recommendation to you at this juncture, is to consult with a plastic surgeon, certified by the American Board of Plastic Surgery, and discuss these issues with them.

A:

Consult a board certified plastic surgeon.  After an examination you will be able to discuss your options.  Doctors do not approve the surgery for the insurance company.  It is your insurance company and the specifics of your insurance policy that predetermines the eligibility for a specific procedure.

Your plastic surgeon can write a letter to your insurance company requesting pre-authorization of the procedure.  THEY MAKE THE DECISION.  Your insurance may require certain documentation from your family physician.  They also may require information on the amount of breast tissue to be removed.  If the amount does not meet their criteria, they then will not cover the procedure.

A:

Approval and Insurance Coverage for Breast Reduction

Your symptoms and apparent breast size make you what we, as Plastic Surgeons, consider a good candidate for Breast Reduction.  Each insurance company has their own requirements before they will approve payment for breast reduction.  You could start by asking your company what their requirements are.  If this looks promising, see a Plastic Surgeon.  He/she will write your company with your specifics, and ask if they will approve your surgery.  You will then know if they will pay for the surgery, or what you need to do to become eligible, if anything.  If they deny coverage, you can always pay for the procedure yourself.

A:

The insurance requirements for a breast reduction can vary but usually include neck and shoulder pain not relieved by physical therapy, removal of at least 500 grams (or three cup sizes) from each breast, and dermatological changes beneath the breasts.  We try and pre-authorize our patients for this. For our out of town patients, we submit the photos that they send us.  It is performed on an outpatient basis and would require at least a five day stay in our area.

Dr. Ed Domanskis

Edward J. Domanskis, M.D., FACS - View Other Answers by this Doctor
Newport Beach, CA

A:

Insurance company coverage for breast reduction depend on the insurance company, the policy you have. so it is important to document all your symptoms with your family physician. Then have a consultation with a Board Certified Plastic Surgeon. After examination and a full medical history the plastic surgeon will discuss with you the surgery and risks. The plastic surgeon can write a letter to your insurance company to PRE AUTHORIZE THE PROCEDURE. Remember pre- authorization from the insurance company is not a guarantee that they will pay.

You can call the insurance company also and ask what are their requirements

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