Does Breast Reduction for D Cup get covered by insurance?

My breasts are D Cups and I need to get a breast reduction. How do I go about making sure that this will be treated as a medical procedure? My have constant back pain and am in and out of the chiropractor every weak. My frame cannot handle these breasts. Help!

CharlineTia

F, 35, California

Whether or not an insurance company will cover breast reduction surgery depends on the specifics of the insurance plan and the severity of any medical problems related to having large breasts.

Without knowing any details related to your specific case or your insurance coverage I can't offer you any insight into whether or not your policy will cover you. However, the fact that you are currently receiving physical therapy for back pain is a good indication that your medical problems are legitimate and that you are not seeking reduction surgery purely for aesthetic reasons.

Depending on your weight and fitness level, some insurance companies will encourage you to begin a weight loss program prior to any reduction surgery. Others will have a set of specific criteria which you must meet in order to qualify for coverage.

I encourage you to consult with a board-certified plastic surgeon to assess the medical necessity of a reduction mammoplasty. If your plastic surgeon agrees that your situation represents a medical condition or is preventing you from performing certain physical activities, they can request certification from the insurance provider.

Dr. Kimberly Henry has 2 Breast reduction before & afters:

Breast reduction before image performed by Dr. Kimberly HenryBreast reduction after image performed by Dr. Kimberly HenryBreast reduction before image performed by Dr. Kimberly HenryBreast reduction after image performed by Dr. Kimberly Henry

» View Dr. Kimberly Henry's full profile

That's a very good question--unfortunately there's no simple answer as to what insurance companies will cover and what they won't. The answer depends on several things including your insurance policy, the insurance company involved, your personal medical history, body weight and specific medical conditions.

Insurance coverage is a complex area and each insurance company has its own set of customized criteria which determine whether or not a procedure is a medical necessity.

If you are experiencing neck pain, shoulder pain or back pain there is chance they may cover the procedure. But keep in mind that insurance companies frequently refuse to cover breast reduction as it’s considered to be a cosmetic procedure in many cases.

Many insurance providers are more likely to cover large reductions from a high breast size (like an F cup) to a medium cup size. Smaller reductions may be considered elective procedures. Sometimes insurance plans will stipulate that a breast reduction must include a specific amount of breast weight, like 500 grams from each breast. Other health insurance plans will make this weight requirement relative to overall body weight or body-mass index, so that smaller-framed women will have a lower reduction requirement to qualify than larger-framed women.

My advice would be to consult with a board-certified plastic surgeon. After your consultation, your surgeon will need to request insurance certification and submit any associated medical evidence suggesting that the breast reduction surgery is medically necessary.

Dr. Neil Zemmel has 2 Breast reduction before & afters:

Breast reduction before image performed by Dr. Neil  ZemmelBreast reduction after image performed by Dr. Neil  ZemmelBreast reduction before image performed by Dr. Neil  ZemmelBreast reduction after image performed by Dr. Neil  Zemmel

» View Dr. Neil Zemmel's full profile

Dear Charline Tia,

Thank you for your question. First I would recommend that you are seen by a Board Certified Plastic Surgeon for your concerns regarding the size of your breasts. Most important is to pick a Board Certified Plastic Surgeon - Certified by the American Board of Plastic Surgery. It can be hard and confusing for consumers when a physician may tell you they are Board Certified. Make sure it is Board Certified in Plastic Surgery as many Physicians are certified but it is in another area such as Dermatology, Gynecology, ENT, or some other specialty that does not have the years of training and Certification in Plastic Surgery required to be a Board Certified Plastic Surgeon.

The surgeon would meet with you, examine you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of the operative procedure in person and what you can realistically expect. Then you can make an informed decision on if the procedure wi meet your desires. He will take measurements and recommend the approximate grams of tissue that would likely be removed from each breast to reach the reduction that you desire. We use a 3D imaging system to take pictures of the patient and this enables us to closely demonstrate what the different reduction options would look like n their actual frame from a 3 dimension perspective

Each insurance company has specific criteria regarding covering breast reduction procedures The Bard Certified Plastic Surgeons office should be able to go over your policy with you and explain your individual policies coverage to you. 

Patient Administrator 
Tim Sayed, MD. FACS

General Inquiries and Patient Consultations: info@timsayedmd.com

Phone: 1-858-247-2933 (1-858-24SAYED)
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Breast reduction can often be covered by insurance. Each insurance company has stringent criteria that are specific. These include complaints of back and neck pain, shoulder grooves, rashes under the breasts, and difficulty finding well-fitting bras. The surgeon will have to submit photos to your insurance and bill your insurance for the consultation visit, which includes the cost of submitting a "pre-authorization" to the insurance company. There is no guarantee of an authorization but many insurers have pretty straightforward processes. If authorization is received, you will still be responsible for deductibles, copays and co-insurance fees (for instance, you will have to meet your deductible if not already met and if you have a 20% co-insurance responsibility, you'll pay 20% of the costs of the surgery). 

The photos are a big part of the process. It does help if you have documentation of chronic pain in the back, neck or shoulders from a physician, chiropractor or physical therapist, lasting at least 1 year.


We have a large number of good before and after photos of breast reduction on our website and additional information:


http://www.timsayedmd.com/breast-plastic-surgery-newport-beach/breast-reduction/


Happy to do a consultation with you. What insurance plan are you on?

-- Dr. Sayed


For more info,


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Email Us at  info@timsayedmd.com

Call Us at     1-858-24SAYED (1-858-247-2933)

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Breast reduction coverage is based on criteria spelled out by your insurance company in their policy.  You have a right to ask for it.  The policy is never based on cup sizes since they are not standard.  It's based on symptoms, history, and your measurements (done by surgeon in person).