Q: I am 24 years old, 5′ 4” tall, weigh 135lbs, and have 38DD breasts. Am I a good candidate for breast reduction and could it be covered by insurance? My back, shoulders and neck are always sore and I get migraines in the back of my head all the time. I wear loose clothes to hide my hideously large breasts and I would never even think of wearing a swimsuit for fear that I might fall of it! I just want to be physically and emotionally happy, but its hard with my unproportioned body due to my large breasts. Insurance is the only way possible for this surgery to happen if I qualify.
A: Based on the size of your breasts and your height and weight, it would seem likely you’re your breast reduction would qualify for insurance coverage based on my experience. But whether one’s medical insurance will provide can not be determined by your plastic surgeon. Insurance coverage for breast reduction requires a predetermination letter to be sent by your plastic surgeon with specific qualifying information. Your height, weight, breast cup size, history of medical symptoms associated with your large breasts, what non-surgical treatments have been attempted, and how much breast tissue in grams is to be removed is the needed information. This letter, complete with photographs of your breasts, will be submitted for their review. They will then determine if you qualify and their decision with be returned by letter to you in about 4 to 6 weeks after submission.
Dr. Barry Eppley
Q: I am a 58 year old female who is looking for a highly qualified plastic surgeon to perform a breast reduction surgery. I need to be able to work with someone who can help me get my insurance plan to cover the cost as I feel this is medically necessary. I honestly don’t have a clue how the insurance works in a case such as mine . My health issues include fibromyalgia, arthritis, diabetes type 2, GERD, chronic depression, and anxiety disorder. I had a back surgery in 2008 for a lower back condition that required a L5S1 partial laminectomy, spinal fusion, surgical hardware, and a bone graft. I have arthritis in the rest of my spine as well. I have many issues with headaches, neck pain, shoulder and back pain. I also have problems with rashes under my breasts and bruising caused by wearing underwire bras for support. My bust size is a 44DD and, although I am not a small person, the size has become a hinderance to me as far as activities, heat intolerance, and the pain I live with daily. Please let me know if you think there is a chance we might be able to have a reduction covered under my insurance. I simply cannot afford to pay for any kind of health care or surgery on my own. Thank you for your time.
A: Breast reduction is often covered by one’s insurance if you qualify by their standard and well-known criteria. These include the following three items that your insurance will evaluate. First, you can not be obese or significantly overweight. One should not be more than 20% over their ideal body weight. If you are, you will be told by your insurance company that you have to lose weight to qualify. Secondly, you must have symptoms of back, shoulder and neck pain that has NOT responded to three months of conservative management such as physical therapy and/or chiropractic therapy. Such treatments must have documentation, not just saying that you have had them. Lastly, the amount of breast tissue that is going to be removed must be of a certain amount based on a calculated number known as your BSA. (body surface area) If the amount of breast tissue that can be removed does not meet the amount based on your BSA, you will be denied.
All of this information is put together in a letter, written by your plastic surgeon, and then sent in to the insurance company. This is known as a pre-determination. One then waits to get back written approval or denial before ever proceeding to breast reduction surgery.
Dr. Barry Eppley
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