Getting Your Insurance Company to Cover the Cost

Getting your insurance company to cover anything these days can be quite a challenge. Your best bet to getting a breast reduction surgery approved by your insurance company is to find a plastic surgeon with a good track record.

In order to get approval from insurance companies, a plastic surgeon, and the patient, must meet a certain criteria. First, your plastic surgeon must estimate that he or she can remove at least 500 grams (one half pound) from each breast. Your surgeon must also show that you have disabling symptoms directly attributable to your large
breasts, and your plastic surgeon must show that you have tried everything under your power to resolve
the macromastia symptoms yourself. Along with this your plastic surgeon must provide photos documenting the need for this operation. Only then will there be a chance that surgery will be pre-authorized by your insurance company.

Recently, however, meeting ALL of the above criteria has STILL not been enough. Most insurance companies now also require that the woman requesting this operation be at or near her ideal body weight. Unfortunately, this is where the catch-22 appears again: Women with macromastia are often unable to exercise because their large breasts are too cumbersome to allow it. So, they are unable to lose the weight necessary to satisfy the insurance company’s requisites for pre-authorization.

Dr. Vennemeyer and Dr. Loftus have found that when they include in their letter to the insurance company the patient’s prior history of macromastia during times of near ideal weight (if applicable), that this information verifies that IF the patient were able to lose weight, that she would still have macromastia and still be in need of the operation. You should ask your surgeon about including this information in your letter or pre-authorization (if applicable in your case).

Of course, even though it may seem unfair that you and your surgeon are made to jump through such hoops, it is critical that both you and your surgeon include only honest information in your letter to the insurance company. Also, remember that even if your insurance company pays for the procedure and even if you use an in-network physician, you may still be responsible for a portion of the cost (check your policy to find out).

FYI – Many of you have inquired about whether Dr. Vennemeyer and Dr. Loftus still perform breast reductions. They do so, and this continues to be one of their most common procedures. Unfortunately, they no longer are on any insurance plans, so the cost is all out-of-pocket. Find out the average cost of breast reduction in the United States, when performed as an out-of-pocket expense.