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

Insurance guidelines for breast reduction surgery

The first thing you’ll want to look into is your insurance company’s medical policy for reduction mammoplasty or breast reduction surgery.

Many insurance companies now require that you have documentation of 3+ months of conservative treatment (ie physical therapy, prescription medications, chiropractic care, etc.) tried and failed along with a mammogram and examination by a plastic surgeon with photo documentation.

It is also very helpful to have letters of support from your family physician, GYN, fitness trainer and yourself stating the symptoms you have any treatments tried (supportive bras, creams for rashes, weight loss, etc) and what activities increase your pain or you are unable to do because of your breast size and discomfort.

Approval And Insurance Coverage For Breast Reduction

The patients who get approval the fastest normally have all the documentation that is required by their insurance company along with supportive letters and a personal letter when they are seen by me and we send all the documentation to their insurance company for approval which can take 2-6 weeks depending on your insurance company. (Peter C. Haines, MD, Columbia Plastic Surgeon)

The 5 Most Important Factors in Getting Insurance Coverage for Breast Reduction

Insurance carriers have become much more demanding prior to approving coverage for the Breast Reduction Procedure: Over a 30 year career we have found the the most important factors in obtaining coverage are:

History: long standing history of multiple symptoms associated with this condition: Bra strap irritation, back problems, neck strain, rashes beneath breast and most importantly a diminished overall activity level.

Breast Reduction Cost With Insurance

A letter from the patients medical doctor documenting the symptoms is also extremely helpful. A well documented attempt at improving the above noted symptoms for at least one year.. including:

• Treatment of rashes beneath breast, physical
• Therapy for back problems, medication: muscle relaxers, mild pain pills (tylenol)

Physical Examination: the weight is extremely important and if you are over-weight your chances of being covered are drastically diminished.

Bra Size: Chest wall measurement and the anticipation of the amount of tissue to be removed from each breast by the examining physician. A prior authorization letter is then sent to the insurance carrier with documentation of all of the above findings with photographs included.

We have our patients fill out their forms with the above information prior to their consultation and most patients will receive a response from the insurance carrier within 2 to 6 weeks. (Joseph Rucker, MD, FACS, Eau Claire Plastic Surgeon)

Getting Insurance Approval For Breast Reduction

The key points to getting insurance coverage when the company has a policy which includes breast reduction are as follows:

• Must have documented neck and back pain not relieved by physical therapy, medication, and properly fitted bras.
• Evidence of shoulder grooving from bra straps.
• Intertriginous rashes near the inframammary fold.
• Finally photographs are usually submitted and these are very important to some carriers in deciding to cover the procedure. (Paul Vitenas, Jr., MD, Houston Plastic Surgeon)

It is nearly impossible to offer a guaranteed method of obtaining approval but if you have tried, and failed, a series of conservative techniques, then it may be reasonable to contact them.

Steps for getting insurance authorization for breast reduction

Before you start the process, you should check with your insurance carrier to ensure that you don’t have a policy which excludes coverage for for breast reduction and to see if your insurance company requires a regimen of physical therapy prior to covering the procedure.

How Do I Know If Insurance Will Cover My Breast Reduction

Your insurance carrier may also mandate that your body mass index be below a certain number prior to authorizing surgery. Unfortunately, BMI doesn’t differentiate between muscle and fat weight; that’s why your doctor is focusing on that and not your body fat percentage.

Once that has been clarified, your first step is consultation with a board certified plastic surgeon. He or she will evaluate whether you are a good candidate for surgery.

Depending on your Body Mass Index, you may need to lose weight prior to surgery to lessen the risks of surgery, improve the aesthetic outcome, and to satisfy criteria from your insurance company.

Your plastic surgeon will need to submit photos to your insurance carrier and will likely need to submit a letter documenting the amount of breast tissue he or she anticipates removing and documenting your symptoms.

The Approval From The Insurance Company

Even with all of that, sometimes insurance carriers are slow to approve the surgery. It is definitely worth pursuing, though, particularly given the symptoms you describe. (Sam Jejurikar, MD, Dallas Plastic Surgeon)

I see many patients in consultation each week who are interested in having a breast reduction covered by their insurance and unfortunately it is difficult to predict exactly which patients will have success in their insurance considering it a covered benefit and which patients will not.

Each insurance plan has their own specific criteria that must be met to deem a breast reduction as medically necessary. This criteria often includes: failure of alternative treatments, a minimum required amount of tissue to be removed (usually at least 500g per side), BMI, extensive documentation of back, neck and shoulder pain, extensive documentation of inframammary rashes, etc…

Will Health Insurance Cover Breast Reduction

To help strengthen ones case for medical coverage, my office will often attempt to obtain documentation in the form of letters of medical necessity from primary care physicians, orthopedic surgeons, chiropractors, physical therapists, and/or dermatologists who have treated the patient in question.

These letters attest to the relationship between the patients large breasts and specific symptoms, and go on to state that these symptoms would be relieved from a breast reduction procedure.

If you are interested in having a breast reduction, I would recommend scheduling a consultation with a board certified plastic surgeon who is well-experienced in these procedures.

At the time of your consultation your options can be thoroughly reviewed and your candidacy for a breast reduction can be best determined. As a necessary first step in attempting to obtain medical coverage for this procedure, your consultation and physical exam will provide great insight as to what predetermined criteria you may already meet and what your chances are in obtaining insurance approval. (Stephen T. Greenberg, MD, Woodbury Plastic Surgeon)

Will Insurance Pay For My Breast Reduction

Very few insurance companies use a formula for this. BCBS tends to use a chart called the Schnur scale but they do not always adhere to its recommendations. Your best bet is to go in for a consultation and have the surgeon compose a predetermination of benefits coverage letter to your insurance carrier. (Otto Joseph Placik, MD, Chicago Plastic Surgeon)

Insurance approval for breast reduction

Go on line and download your insurance carriers criteria for breast reduction surgery. If you do not meet these criteria, I can guarantee they will not preapprove your surgery. In general, many insurance companies will require that you have failed conservative treatment of your back, neck and shoulder pain before approving surgery.

Insurance Company Coverage For Breast Reduction Depend On The Insurance Company

This includes no improvement in your symptoms with medication prescribed by your family doctor, no improvement after seeing a chiropractor/ physical therapist or after losing weight. A letter from your family doctor or chiropractor/ physical therapist would also help.
You will also need to see a board certified plastic surgeon who will need to submit a letter and pictures to your insurance company seeking approval. (David A. Robinson, MD, Munster Plastic Surgeon)

Insurance to approve breast reduction

TRY by seeing a boarded plastic surgeon who will then submit to your insurance company a predetermination letter with photos of your breasts. Other information will also be included. THAN IT IS A WAIT. It is like a game of who’s it.

Keep calling the insurance company, become a pain to them. Keep asking why, what, and when. (Darryl J. Blinski, MD, Miami Plastic Surgeon)