Breast Reduction and Insurance Coverage
Q: I am a 23 year-old graduate student and former college athlete. My breasts are so large I am miserable all the time and can’t even run anymore. I wear a 36DDD bra and this puts too much strain on my body. My shoulders hurt all the time. I have been in physical therapy for my neck and back, have migraine headaches and asthma. I am 5’ 10 and weigh 190 lbs. Will insurance pay for my breast reduction?
A: Breast reduction surgery is commonly covered by insurance but not always. There are certain very specific qualifications that all health insurances require that a patient must meet to be eligible. These include being within 20% to 25% of their ideal body weight (not being too overweight), having a documented history of physical therapy or chiropractic treatments for three months that did not result in sustained pain relief (emphasis on being documented), failing other non-surgical therapies such as anti-inflammatory drugs and support bras (all patients meet these criteria), and having your plastic surgeon document the specific amount of grams that will be removed that meets the minimum amount based on your body surface area calculations. (estimated by your plastic surgeon) All of this information will be put in a letter by your consulting plastic surgeon and sent in with photographs of your breasts to your insurance carrier for their determination.
Generally, if all of these criteria are met a patient will be approved for breast reduction surgery. The most common reasons patients are rejected coverage is because they weight too much for their height, have not tried some form of physical therapy, or not enough grams of breast tissue are estimated to be removed. (in this patient based on height and weight, the BSA is 2.05 with a requirement of at least 1,000 grams removed per breast)
While any amount of breast reduction provides relief in all patients, and a patient’s weight or amount of breast tissue to be removed has not been proven to matter for pain symptom relief), these are the insurance criteria. Debating their merits with the insurance company is not a productive endeavor.
In patients where insurance coverage has been denied, breast reduction surgery can always be done on a fee-for-service basis. Your consulting plastic surgeon will be happy to provide you with a cost estimate.
Dr. Barry Eppley
A detailed description and pictures of your concerns allows for the most informed response.