Help with tips to get my breast reduction approved by insurance?

I am a size 38DD and my breasts have always been very heavy and has caused me to have neck pain. I have been this size for so many years and it is getting more and more unbearable. I have been doing some research breast reduction surgery and I have read that in some cases insurance will cover the surgery or at least a portion of it. Can you please recommend some helpful tips that I can follow to get my insurance company to approve covering at least part of my surgery?


F, 48, New Jersey

Breast reductions can, in some instances, be covered by your insurance company. Generally speaking, breast augmentation -- enlarging the breasts or making them perkier -- is considered a cosmetic procedure, and as such not covered by insurance.

However, there is a point when breast reduction moves from cosmetic to a medically indicated procedure and might be covered by your health insurance company. That point is usually crossed when the procedure is considered reconstructive surgery based on the medical needs of the patient. Those "needs" are usually found in patients who experience back and neck pain emanating from the size and weight of their breasts, or from bra straps cutting into their shoulders.

Your first step should be to check with your insurance company. Have them review your policy and provide you with the criteria required for coverage related to reduction mammaplasty (breast reduction). Make sure they send it to you in writing.

Ask your health insurer if you need to start with a primary care physician to get the ball rolling or if you can go directly to a plastic surgeon to inquire about this procedure. If the latter, make sure they are a board-certified plastic surgeon approved by the American Society of Plastic Surgeons (ASPS).

Don't be discouraged if this doesn't come together overnight as it can sometimes takes weeks -- or even a few months -- to get all the necessary approvals.

The short answer is that sometimes breast reduction is covered by insurance; other times it's not. The difference is one of medical necessity, meaning there has to be a medical reason why you need to have breast tissue removed. From your question, it appears you've been suffering pain and discomfort for years. You should be a good candidate for coverage, but it’s hard to predict how these things will turn out.

For starters, you should contact your insurance company and see what the criteria is for coverage. Some insurance companies will pay when the surgery is necessary to reduce back and neck pain, shoulder pain, and so on. The insurance company, however, will probably ask you and/or your doctor for documented evidence of the medical need for the procedure. Don't be offended if they first suggest weight loss, chiropractic treatment, visiting a physical therapist, etc. The insurance company may be looking at alternative options before they give you the go ahead that they'll cover breast reduction.

You would think that plastic surgery to reduce breast size that causes pain would be a no-brainer, but we've seen a number of cases where insurance plans ask for a lot of documentation. The earlier you engage your insurance provider and medical professionals, the quicker you'll have your answer.

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

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