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Q.

how hard is it to get my insurance provider to cover a breast reduction?

I am 22 years old about 5'9 and 180lbs with a 38g cup size.  I am in horrible pain and don't know how to go about getting one or how to get my insurance to approve it.

Related Topics: Insurance, Breast, Pain
 

Answers From Experts & Organizations (1)

Health Reform
924 Answers
977 Helpful Votes
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A.

The bottom line when it comes to having insurance pay for  any procedure is whether it's considered medically necessary. In the case of a reconstructive procedure like the one you're asking about, that generally means it is needed to repair or preserve the healthy functioning of the body.

It sounds like for you, breast reduction surgery may be medically needed, whereas for another woman it could be considered a cosmetic procedure. Circumstances matter.

I would start the process by getting in touch with your insurer to find out what's needed to get the surgery covered. You're likely to need your plan's pre-authorization. That will also mean getting your doctor to submit specific information about your circumstance and why he/she believes the surgery is medically needed. Insurers often have very specific requirements in order to approve such a surgery, so it will be important for both you and your doctor to learn what they are, and then to follow your plan's rules to submit the necessary paper work and justification for the procedure.

If you're initially denied, be aware that you do have the right to appeal your insurer's decision, and you should. Don't take no for an answer without fighting for the care you need. Appeals do often turn in favor of the patient.

Best of luck!


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