Breast Reduction Weight Requirements by Insurers

Reduction Mammaplasty Insurance Requirements on Weight

Also known as reduction mammaplasty, breast reduction surgery aims to decrease the size of female breasts to meet cosmetic or physical goals. For a significant number of women, having excessively large breasts can cause all sorts of problems, from back and neck pain to shoulder grooving and rashes. In 2017, there were 43,635 aesthetic breast reduction patients in the US alone, an 11 percent increase from the previous year. Many more received this procedure as a corrective treatment for symptomatic macromastia (large breasts). These numbers demonstrate the increasing prevalence of breast reduction surgery.

If you’re thinking about undergoing a breast reduction surgery, this article explores the issue of insurance coverage and required qualifications.

Is Breast Reduction Covered by Health Insurance?

Breast reduction is considered to be a cosmetic procedure (which is not usually covered by insurance) until the patient can demonstrate a number of associated health issues and attempted treatments. Male and female patients who are seeking breast reduction must show that they have tried other medical treatments and sought prior consultations regarding macromastia before settling on surgery. This may include showing a history of referrals for chiropractic treatment or physical therapy focused on elevating the physical symptoms of excessively large breasts.

For breast reduction to be covered by insurers, a lack of documented history by the patient could prove to be an issue.

Insurer Criteria for Coverage of Breast Reduction Surgery

Insurers typically rely on a number of things to establish whether your reduction surgery qualifies for coverage.

  1. Medically indicated signs and symptoms – insurers rely on special references of medical problems under the International Classification of Diseases (ICD) codes. Some of the physical symptoms that may be recognized by insurance companies in relation to excessively large breasts include postural backaches, upper back pain, neck pain, skin irritations (intertrigo), and pressure causing numbness.
  2. Body mass index – the BMI is a special system that compares the weight and height to establish an individual’s weight status. Some companies may refuse to pay the bill for breast reduction surgery unless the patient’s BMI is less than 30. Others will only accept BMI that is less than 35, while some companies require documented proof that the patient has tried to lose weight either through exercise, diet, or weight loss surgery.
  3. The weight of tissue to be removed – insurance companies will also rely on the amount of tissue to be removed from each breast to determine whether or not the reduction patient qualifies for coverage. Depending on the company, this weight requirement may be 450 grams, 500, or even 600 grams. Some insurers leverage a much more detailed approach to ensure they do not penalize patients with a smaller stature but disproportionately large breasts. 90 percent of times when the patient meets these weight requirements, coverage is provided. Women who have DD, DDD and H cups typically qualify.
  4. Matching reduction after breast cancer – coverage is provided in cases where the patient needs to have reduction surgery to balance a larger, healthy breast with one that was affected by cancer treatment. This is provided for by the 1998 Women’s Health and Cancer Rights Act. The legislation covers reconstructive treatment on a breast affected by cancer, as well as balancing procedures for the healthy breast to match the reconstructed one.
  5. Evidence from other physicians – before you even get to your breast reduction in Scottsdale AZ from a surgeon, your insurer may require that you provide supportive letters from other physicians requesting breast reduction to treat macromastia symptoms. Letters documenting alternative remedies such as physical therapy, weight loss, and exercising in an attempt to correct the situation will also suffice.
  6. Photographs and measurements – your breast reduction surgeons may need to provide de-identified photos (from the neck down) and specific measurements quantifying your breast size in relation to your frame.

If you feel like you may be a good candidate for breast reduction coverage, get in touch with your insurance carrier and ask them to forward (in writing) the criteria for coverage. Different insurance companies have different indications and criteria. Also, keep in mind that it takes about 3-6 months (on average) of preparations before you can seek the insurer’s intervention. This preparation entails consultations with other practitioners for alternative remedies such as chiropractic or physical therapy.

Dr. LaBarbera Breast Reduction Surgery

Gilbert breast reduction surgeon Dr. LaBarbera has helped countless women alleviate physical symptoms and achieve their desired breast size. Dr. LaBarbera works with reduction patients in the Scottsdale, Gilbert, and surrounding AZ areas.

Although having large breasts is often seen as a desirable trait, Dr. LaBarbera understands that they can also cause emotional or physical discomfort. Many of his patients are women who have suffered from chronic neck pain, back pain, rashes, and other symptoms. Dr. LaBarbera also works with individuals who are looking to decrease their breast size in order to achieve cosmetic goals. He takes each case as unique and formulates an individualized treatment plan to achieve the best possible results.

Your first breast reduction consultation with Dr. LaBarbera

If you’re in Arizona and contemplating breast reduction or what to expect after breast reduction, visit Dr. LaBarbera at his Gilbert practice. The surgeon will sit down and discuss your large breast concerns as well as expected outcomes of the procedure. You may also view out breast reduction images For patients who have physical symptoms and are looking forward to health insurance coverage, Dr. LaBarbera will guide you on the way forward. This initial visit is also an excellent opportunity to ask any specific questions that you may have regarding this procedure. Most patients who have received a reduction from Dr. LaBarbera say they are satisfied with the results and are happy with the professionalism of his team.

Get in touch with Dr. LaBarbera now and chart a path forward for your breast reduction treatment.

Jude LaBarbera Md Plastic Surgery of Scottsdale
8900 E Raintree Dr #400B
Scottsdale, AZ 85260