Breast reduction/Insurance ?

[Bernadine]

If you’ve had a reduction, was it covered by your insurance? If so, was it difficult to get approved? I’m just starting to explore the option and wondering what I’m in for.

[7costanza]

I recently looked into a reduction/lift but decided against it. I spoke to my insurance company’s concierge program and it sounds like it’s not too hard to get it covered, here are the requirements they sent me. Your insurance may be different but hopefully this gives you an idea of what they’ll look for:

The individual meets the minimum specimen weight of breast tissue to be removed based on the individual's body surface area (BSA) and the Schnur scale (refer to Guideline section for Schnur Scale).
One of the following clinical symptoms is present for a minimum six-week period:
Back pain from macromastia unrelieved by conservative measures (e.g., support bra, exercise, heat/cold treatment, non-steroidal anti-inflammatory drugs [NSAIDs]/muscle relaxants) or physical therapy.
Significant arthritic changes in the cervical or upper thoracic spine that has not responded to conservative measures (e.g., support bra, exercise, heat/cold treatment, NSAIDs/muscle relaxants or physical therapy)
Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to dermatologic treatment measures that have not responded to a completed course of medical management.
Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening that has not responded to appropriately fitted support garments.
Graphic documentation of ptosis with nipple areolar complex 8 cm below the inframammary crease.

[Bernadine]

Jul 8, 2022 9:37:12 GMT -5 7costanza said:

I recently looked into a reduction/lift but decided against it. I spoke to my insurance company’s concierge program and it sounds like it’s not too hard to get it covered, here are the requirements they sent me. Your insurance may be different but hopefully this gives you an idea of what they’ll look for:

The individual meets the minimum specimen weight of breast tissue to be removed based on the individual's body surface area (BSA) and the Schnur scale (refer to Guideline section for Schnur Scale).
One of the following clinical symptoms is present for a minimum six-week period:
Back pain from macromastia unrelieved by conservative measures (e.g., support bra, exercise, heat/cold treatment, non-steroidal anti-inflammatory drugs [NSAIDs]/muscle relaxants) or physical therapy.
Significant arthritic changes in the cervical or upper thoracic spine that has not responded to conservative measures (e.g., support bra, exercise, heat/cold treatment, NSAIDs/muscle relaxants or physical therapy)
Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to dermatologic treatment measures that have not responded to a completed course of medical management.
Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening that has not responded to appropriately fitted support garments.
Graphic documentation of ptosis with nipple areolar complex 8 cm below the inframammary crease.

Thank you, this is helpful. Can I ask why you decided against it?

[glitzy07]

I had a breast reduction in 2019 that was fully covered by my insurance. I had dual insurance at the time. Primary coverage through my job and then secondary coverage from my husband's policy. I had to get pre-approval from both companies and was initially denied by my insurance. I worked with my doctor to submit an appeal after the denial and then they ultimately approved it. There was a requirement that I had to have a minimum amount of tissue removed for it to be considered medically necessary and covered and my surgeon was comfortable with the amount required. In the end he ended up taking even more tissue than the minimum.

I'm happy to share if you have any other questions about the process. Just message me or tag me here! It was 100% the best thing I've ever done for myself.

[7costanza]

Bernadine The number one thing was the potential for loss of nipple sensation. To get the aesthetic results I wanted (cleavage, lol) I would also need implants, which I’m not interested in and makes no sense to get a reduction and add implants. I don’t have severe physical symptoms so at this point I don’t feel like it’s something I need. I would love for them to be less saggy, but I’m happy enough with how things are for now and am just going to focus on finding good quality bras and clothes I feel good in.

[egishere]

I had mine in 2000 so I don't know how much things have changed but it was very simple- the plastic surgeon wrote a letter and had to submit photos too I believe and it was approved.

7costanza, just curious if you got more than one opinion? The implants make no sense to me. I have cleavage and my nipple sensation is fine. I had mine done more than 20 years ago and yes I have some sagging after kids etc but they aren't to the point where I need a lift etc.

[doggielover]

I had mine done way back in 1999 and it was covered by insurance. My surgeon I think had to write a letter but they approved it no problem. I'm sure things have completely changed since then but I'm still glad I had it done.

[gottadobe]

Jul 8, 2022 9:59:04 GMT -5 egishere said:

The implants make no sense to me. I have cleavage and my nipple sensation is fine. I had mine done more than 20 years ago and yes I have some sagging after kids etc but they aren't to the point where I need a lift etc.

I had a reduction years ago and then needed another (   ) and got implants for upper pole volume. Otherwise, with a reduction they are smaller but not "full."

[7costanza]

Jul 8, 2022 9:59:04 GMT -5 egishere said:

I had mine in 2000 so I don't know how much things have changed but it was very simple- the plastic surgeon wrote a letter and had to submit photos too I believe and it was approved.

7costanza, just curious if you got more than one opinion? The implants make no sense to me. I have cleavage and my nipple sensation is fine. I had mine done more than 20 years ago and yes I have some sagging after kids etc but they aren't to the point where I need a lift etc.

I just saw one surgeon but based on the many before and after pictures I’ve seen I do think the implants would be needed in my case to create fullness up top. I definitely need a lift after two kids Luckily I can mostly fake it with a good push up bra.

[sadlebred]

1999 here. The surgeon submitted photos and a letter. There was a minimum he had to take out, and he took out more. Cost me $60--surgery, meds, everything. I think the $60 was prescription copays if my memory is correct.

[shakinros]

Lurker here! I called one place that said they wouldn’t see me even for a consult without:
- 6mos of physical therapy records documenting back pain
- a BMI under 30

Visited another surgeon who submitted photos of my shoulder grooves and measurements but it got denied. My primary suggests that I see a chiropractor to build a paper trail and try again.

I have two coworkers who had reductions in the last couple years but I’m both cases, they’d already tried several months of p/t or chiropractor treatments for back and neck pain. It does seem that evidence of other treatments being tried first is required to get insurance to cover it!

[Doggy Mommy]

Another lurker here. I had a consultation with one surgeon and canceled a consult with another after they told me it would be 7k more than the other guy. When I scheduled the consults the person I scheduled with was sure to tell me that they don't take insurance for breast reductions. I've seen that on other surgeons websites in my area too.

I have Kaiser for insurance, and I'm going to get a consultation with them. I'm reallllly not excited to go with Kaiser but not sure exactly why. I'm going to look into it though.

I wanted to get it done this summer, but didn't go through with it. Still thinking about it though and still have the back pain etc.

[stemmie]

A family member of mine has done this twice. Hers grew back despite maintaining her BMI around a consistent 21.

The first time insurance paid. She had documented neck pain, recurrent yeast infections and big dents in her shoulders. There was a requirement for a specific amount of tissue to be removed that was expressed in liters. I don't recall her having to try conservative measures first, but this was along time ago when the procedure was less common and the insurance industry was different.

The second time she did not quite meet the insurance criteria for the amount of tissue needed to be removed (this time expressed in pounds/ounces) on both sides. She paid OOP, but I think part of the cost was shared by insurance because she had a lipoma removed at the same time.

[flex]

I have and insurance did not cover the cost.

[boiler717]

I am interested in getting one but I think I would need implants or a lift too. My boobs are basically like melons stuffed in tube socks that hang very low. I don’t think just a reduction would help. I had seen a Chiro for back pain so maybe I should keep that up to establish a paper trail.

[woodgnome]

I can’t speak to the insurance piece because mine was covered due to being BRCA positive and it was a prep surgery for a mastectomy. However, a breast lift is part of a reduction so that’s a given. I’m so glad I had it done- I had wanted it forever and it’s been amazing. The recovery was really not bad at all either. I was 95% back to normal by 2 weeks and 100% by 6 weeks. I was skiing at 7 weeks post-op!

ETA- I had no loss of nipple sensation at all.