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Breast Reduction

Will state insurance cover breast reduction for a 16 year old

miasurrl9 south milwaukee, WI
6 months ago

So I have state insurance and I am 16, i turn 17 in may. I have an E cup and recently I have been having very bad neck and back pains and headaches and i have a rash in between and under my breasts. I went to my doctor and she said to start doing physical therapy first to show the insurance that im trying other options first, but would state insurance cover it if i am 16?


Tracy McCall, MD Waukesha, WI
6 months ago

State insurance does cover breast reductions. There are several types of Medicaid. Some of them will give you problems if you are under 18. The best thing to do is to submit a letter for preauthorization and see what happens. You can ask your primary care doctor for a referral to a plastic surgeon. There are several in your area who are really very good. There is also the medical college. You can find board certified surgeons on this site and also on the Wisconsin Society of Plastic Surgeons website.

Nelson Castillo, MD Atlanta, GA
6 months ago

Thank you for sharing your excellent question. If you can show documents from conservative treatments like PT that do little to improve your back and neck pain and headaches then you may qualify for a reduction. Depending on size it would be best to wait until your breast growth has stabilized to achieve a more consistent result. Hope this helps.

Rahul Vemula, MD Wall Township, NJ
6 months ago

Thank you very much for this excellent question.

Managed Medicaid plans differ from state to state with rules and criteria for covering breast reductions.

I would call your insurance provider first to see exactly what your specific plan requirements are.

In general most managed Medicaid plans follow Medicare guidelines set by CMS. For this it must be demonstrated and documented that reasonable attempts have been made to relieve symptoms such as neck and back pain. These include but not limited to pain medication, physical therapy, evaluation by an orthopedic surgeon, and weight reduction.

You must also have grooving from your bra straps that is 1 cm deep.

In addition, if you have skin rashes and infections underneath your breast folds which are worse in the summer months you may qualify. You must also be under the care of a dermatologist and must have documented failure of topical therapy for these rashes.

You must also wait until your breast growth has been completed.




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