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Do I qualify for a breast reduction and will my insurance cover the procedure?

Q:

I'm 20 years and my bra size is DDD cup. There are a few health issues that are starting to concern me: 1) shortness of breath 2) my breasts become sore when not wearing a bra 3) pain in lower back, neck, shoulders has become more intense. I have an altered disc in my lower back and a large amount of muscle mass in my chest due to the weight of my breasts. I'm curious to know if a breast reduction would be the right choice for me? Also, if my health insurance would most likely approve of the procedure?

A:

Elayne,

 

 Consider starting by calling your Insurance Carrier to see if Breast Reductions are a covered service. If they are ask for the list of their requirements for your Breast Reduction to be payed as a covered service & a list of plastic surgeons that take/ accept their/ your insurance plan. Then, consider a consultation with an ASAPS Member in your area that is on your insurance carriers provider list to address your concerns. 

Best,

 

Gary R Culbertson, MD, FACS

A:

Thank you for your question.  Your breast are most like large enough to qualify for a breast reduction.  The insurance company usually requires your breast size to be at least a DD.  You did not include your height and weight and this sometimes play into their decision  for approval.  However, it is very difficult to say if your body symptoms will go away.  Consulting with a board certified plastic surgeon to provide a through evaluation.  Then he/she can help you decide if a breast reduction is the right choice for you.

A:

You may very well be a good canddiate for a breast reduction.  Whether or not it is covered by health insurance depends on the company and specific plan that you currently have (there are hundreds of variations on these). Typically insurance carriers like you to meet several qualifications before approve the reduction. You will want to call your insurance to find out what their criteria is, what documentation they require, and how much of the surgery cost they will cover - -that is to say, co-pay and deductible.

It is best to start at your primary care doctor, talk to them as to what problems your breast are causing you. Most insurance companies require that there is at least 500cc of breast tissue that needs to be removed (given that you are a DDD, you probably have at least that amount). You also should be within 20 % of your ideal body weight.   Furthermore, some require that you have tried conservative measures for relief of the symptoms like motrin, physical therapy, etc. Best of luck to you, I hope this information helps.

 

A:

Women with the symptoms you describe certainly can benefit from breast reduction surgery.  Even if your insurance company declines, you might consider affordable surgery through a board certified plastic surgeon with an accredited office surgical facility.

Your insurance company will make the determination whether they will pay, but your surgeon can submit the prior approval letter after your examination.  Select some for consultations.

I recently posted a blog on this subject which is pertinent to women in our area.  Your area may have different requirements. http://www.expertplasticsurgeon.com/blog/2014/06/03/breast-reduction-insurance-company-requirements-145072

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