Will Insurance Cover My Breast Reduction Surgery?
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
A detailed description and pictures of your concerns allows for the most informed response.