The most common reasons for breast reduction surgery (i.e., reduction mammaplasty) are mainly for the treatment of symptomatic macromastia known as large breasts.

A lot of women suffer from this discomfort due to symptoms that include chronic neck, shoulder, and back pain caused by the weight of the large breasts upon the musculoskeletal system. Sometimes the symptoms extend further and cause breast pain and dermatitis or rashes beneath the breasts.

Seeing that this is described more as a health issue than not, many wonder why there is an unclear opinion as to whether one’s health insurance should cover the treatment of macromastia through breast reduction surgery. Well, this post clears up the confusion.

Breast Reduction and Health Insurance

Most health Insurance companies consider breast reduction surgery a cosmetic undertaking until patients prove the operation to be medically necessary, which is a very cumbersome process. In cases where health insurance might cover macromastia surgery, one will have to provide the following to the insurance company to prove that it’s not cosmetic but rather reconstructive.

• Previous medical treatment or consultations for macromastia.
• History of being referred for physical therapy or chiropractic treatment by an orthopedic consultation or a dermatology exam.
• Photographic documentation of “breast hypertrophy” or overgrowth.
• Persistent symptoms, in multiple areas of the body, that are directly caused by heavy breasts and have occurred for a specified length of time.
• Pain that fails to improve after a months-long trial period of nonsurgical treatments.
• A recent statement from a plastic surgeon test that the patient’s symptoms are due to overly large breasts and that a breast reduction will likely improve them.

For many other health issues, lack of treatment history might not be an issue. But unfortunately for breast reduction, which can be considered cosmetic by the insurance company, the lack of history for this patient would prove problematic. More so, even with this evidence, there is still no guarantee that insurance will cover the cost of breast reduction.

Reason for Breast Reduction Coverage Denial

Insurance companies deny coverage for a variety of reasons. Some common reasons for a breast reduction coverage denial include.

• Contract exclusions.
• Dealing with out-of-network physicians.
• Incomplete or improper documentation
• Sending proposals for the removal of little tissues may not appeal to the insurers as a big problem that requires medical help.
• Not meeting the criteria set by the insurer. For example, physical therapies.

Criteria for Health Insurance Coverage on Breast Reduction Surgery

The only criteria for coverage of breast reduction are to demonstrate that the procedure is medically necessary and not cosmetic. Insurance companies tend to define “medically necessary” as “something that is impacting someone’s physical health to the extent of affecting their quality of life and their ability to function.” Which of course are the back pain, shoulder, and neck pain caused by macromastia. If this is not proven, then there will be no coverage.

FAQs

What Happens After My Insurance Company Approves?

If your breast reduction gets approved, your insurance company will cover the cost of your surgery. Sometimes there is a mandatory number of grams of tissue to be removed from each breast before this approval, which is why some surgeons do not perform breast reduction surgery under insurance coverage. Plastic surgeons find insurance criteria for covering a breast reduction to be largely controversial, unfounded, and limiting. Although, if you choose a surgeon with the experience of insurance preauthorization process, you stand a good chance of getting the surgery paid for.

How To Get Insurance to Cover Your Breast Reduction Surgery

For your health insurance to cover your breast reduction surgery, there are things you should do. The first thing is to carefully document all symptoms related to your breasts. Insurance companies are more likely to cover costs if there is proper documentation and information. For example, if you have frequent back pain, you should note down the intensity of the symptoms and whether they change or get worse over time. Other common health issues related to enlarged breasts:

• Difficulty or inability to exercise.
• Numbness in the chest area
• Persistent pain in the chest, shoulders, neck, and back
• Shortness of breath due to the weight of the breasts
• Recurrent skin rashes and infections beneath the breasts
• Poor body image and low self-esteem

Also, Insurance companies may require 6-12 month documented reports from other referred specialists before coverage is approved.

How Often Do Breast Reductions Get Covered by Insurance?

According to researchers, after reviewing 295 preauthorisation’s, they found out that 72% of breast reduction cases were approved by the insurance companies, which is encouraging.

What Is the Cost of Breast Reduction Surgery?

According to realself.com, breast reduction surgery costs about $8,475 on average. However, this is exclusive of the additional costs incurred during the process, including the operating room facilities charges and the anaesthesiologist’s fees. Many factors affect the total cost of breast reduction surgery. Like any other procedure, it largely depends on the following:

• The surgeon’s experience and reputation
• Extra examination procedural fees
• Prescribed medication
• The geographic location of the clinic
• Type of breast reduction surgery procedure.

Conclusion

The issue of health insurance cover for breast reduction surgery may not be complicated. However, it will involve many variables. And so, patients need to make their findings regarding their insurance coverage for any surgical procedure before seeing a surgeon.