Breast Reduction: Info, Prices, Photos, Reviews, Q&A

Breast reduction has one of the most satisfied patient populations of any plastic surgery procedure. Whether or not insurance will cover the procedure really depends on your specific plan.

Each insurance company will have many different plans and sometimes an employer may set their own rules for coverage. Over the last 5yrs it hase become increasingly difficult to get approval for breast reduction.

The criteria that each patient has to meet and the amount that has to be removed have become more strict recently.

The best thing to do is consult with a board certified plastic surgeon and see if you are a candidate and what your options are once they have reviewed your insurance company and specific plan.

With higher and higher deductibles and copays these days you may want to ask how much it would cost if there is no insurance coverage. You may be surprised that your deductible could be higher. (Bahram Ghaderi, MD, Chicago Plastic Surgeon)

Most insurance companies would cover the reduction of extremely larger breasts in symptomatic patients. If the patient has a history of bra strap grooving, neck and back pain that is documented it has a good chance of getting covered provided that you fall within macromastia criteria consistent with your height and weight. (Steven Wallach, MD, New York Plastic Surgeon)

Insurance for breast reduction surgery is highly variable. Often there are a number of conditions that must exist before your insurance would consider it medically necessary. This includes presence of infection, rashes, ulcers, back pain, shoulder grooving.

However, some are qualified by requiring you to have enough pain to require analgesics, or to see an orthopedic surgeon or therapist or chiropractor for a minimum amount of time.

Some require you to be within a certain percentage of your ideal weight.

Volume removed is often used with some plans requiring a certain absolute volume while others rely on photos. I recommend to patients that they first be honest with themselves about why they are having the surgery.

If they are mainly concerned with the appearance and they try to get covered under insurance, they might end up doing a procedure that does not get them what they want. In the end, if it is medically necessary because of the indications I mentioned, you will be “forced” to proceed with surgery but might need to argue to your case in the event the claim is denied.

If you are afraid to do the surgery because of insurance coverage and end up not doing it, then to the insurance company, you have proved that it is not medically necessary because you have foregone treatment.

Certainly try to find out all you can about the requirements. (Robin T.W. Yuan, MD, Beverly Hills Plastic Surgeon)

Every insurance company has their own criteria. You should check with your company. Your doctor should be able to show you what the reduction amount looks like by showing you that size of breast implant.

It gives you an idea of what will be removed and what you will have left in place. (John P. Stratis, MD, Harrisburg Plastic Surgeon)

Breast reduction size is only one factor in determining insurance coverage

It has become more apparent with the recent health care debate that insurance is a regional issue and coverage will differ widely state to state, and locally plan to plan.

People are also discovering that a company such as Blue Cross will issue dozens of differing plans with differing levels of coverage.

Generally most feel that because of the fact that they have insurance they must be covered for what their doctor feels is necessary care. Unfortunately what is necessary is increasingly determined by your insurance company, or after age 65 by what is allowable under Medicare.

In the Chicago area many years ago as a plastic surgeon we knew an approximate weight of breast tissue which should be removed based on a given patients body mass index to qualify the procedure as necessary and coverable by medical insurance.

In the current insurance climate we now rely on a written predetermination from the insurance company as the amount of breast tissue removed is only one factor in insurance coverage.

In our area Blue Cross PPO has over 10 criteria and patients must meet every one to qualify.

Other plans have been more generous and HMO plans here have been more reasonable to work with. (Peter E. Johnson, MD, Chicago Plastic Surgeon)

Breast reduction size for insurance coverage

First, you need to look at your insurance book to see if your PARTICULAR policy even pays for breast reduction surgery. Each insurer sells different VERSIONS of its policies and just because you have let’s say CIGNA does NOT mean that YOUR policy is the same as your neighbor’s.

They are not. IF your policy does not pay for it, you will not be able to change their mind by writing letters. The law is on their side and frankly you are wasting your time.

If your policy does pay for this operation, look and see which plastic surgeons in your area work with them. Again, not all doctors work with all policies and all insurance companies in every area.

The doctors who DO work with each insurance company will be familiar with what each company requires for it to pay for the surgery. It USED to be 500 grams removed from each side – but most have moved away by either raising this weight (which is grossly unfair to shorter women) or by adopting The Schnur classification which relates the amount that needs to be removed from each breast to a formula relating height and weight — more fair in my opinion.

The latter is the way Blue Cross Blue Shield of Tennessee operates. (Peter A. Aldea, MD, Memphis Plastic Surgeon)

Insurance coverage for breast reduction is inconsistent

This is one of the most inconsistent issues in our health care system. Your insurance company has certain”guidelines” to allow coverage for different procedures. You are required to present lengthy documentation to prove that this procedure is necessary.

Once approved, the insurance company issues a pre-Authorization letter to your doctor.

The twist here is that pre-authorization is not a guarantee of coverage and payment! Which means that you could be left with the bill to pay! It is very tricky! One way to help take matters in your own hands and contact the insurance company and try to hold them responsible. (Hisham Seify, MD, PhD, FACS, Orange County Plastic Surgeon)

There are no hard and fast guidelines for breast reduction coverage or insurance elegibility

It’s not necessarily the size and different carriers use different methods to determine elegibility for coverage. BCBS commonly uses the Schnur scale based on BMI and estimated weight of resected tissues. However, they are not always consistent and it has been my experience that they do not always follow these guidelines.

Your best bet is to go for a consultation and have a letter submitted to determine your level of benefit coverage. (Otto Joseph Placik, MD, Chicago Plastic Surgeon)