It’s not always easy to find a medically necessary breast reduction surgeon who will work with your insurance. Plastic surgery typically isn’t covered by medical insurance, as many plastic surgeries are cosmetic, so many offices won’t work with insurance companies at all. The providers listed on your plan may not be the right specialty or could have extensive waiting lists. To get the result you want, you may have to get creative in how to find the best breast reduction surgeon for your insurance.
When Insurance Covers Breast Reductions
Before you start searching for providers, you’ll want to check the criteria for medically necessary reduction mammaplasty in your insurance. That’s the medical term for breast reduction surgery. Most insurance plans follow similar criteria for it. There are three basic provisions; two go together and one stands alone.
- Chronic pain or skin conditions: Surgery is considered medically necessary if it’s used to resolve a condition that would not resolve otherwise. Most insurance companies list issues with neck or back pain, ongoing painful skin rashes, or a condition called thoracic outlet syndrome as qualifying criteria. Typically, you have to show that conservative treatment has failed and that you’ve had at least three months of it.
- Schnur scale calculations: Insurance companies follow something called the Schnur scale, which tells them whether your surgery is cosmetic or medically necessary based on how much breast tissue is expected to be removed. Calculating this is best left up to a qualified plastic surgeon, as it involves a complex measurement of body mass size, breast size, and an estimated weight of breast tissue to be removed. Typically, someone who meets the first criteria will meet the requirements under this one as well.
- Symmetry after a mastectomy: For this one, you’ll also need to look at another section called “breast reconstruction” in your insurance policy. If the surgery is to help you regain symmetry due to a cancer-related mastectomy, then it is covered under breast reconstruction. This coverage is mandated by state and federal law. You don’t have to meet any chronic pain or Schnur scale requirements—because it is related to a mastectomy, it’s typically covered.
Knowing when insurance covers breast reductions is only half the battle—you must also find a surgeon who is willing to work with your insurance company. This can be a problem, as many plastic surgeons don’t work with insurance at all.
How to Find the Best Breast Reduction Surgeon for Your Plan
Plastic surgeons typically don’t work with insurance companies because often, they’re providing elective cosmetic care that’s not covered under policies. The ones who do provide medically necessary plastic surgery will specialize in a specific area like the hands or the skin. The few breast reduction specialists available on that list could have extensive waiting lists. They also may not be the best provider for you.
A better strategy may be to go out-of-network. Many people confuse out-of-network with “doesn’t accept insurance,” but that’s not what it means—it just means the insurance company doesn’t have an existing contract or fee schedule with that provider. Your policy may also have higher out-of-pocket costs associated with it.
However, out-of-network costs for medically necessary plastic surgery can be comparable to in-network. An out-of-network provider can negotiate bills with you to minimize your out-of-pocket costs because they’re not bound by a contract. There are also a lot more out-of-network plastic surgeons available.
Here are some tips for how to find the best breast reduction surgeon to work with your insurance, regardless of whether they’re in-network or out-of-network.
Explore Different Techniques
There are two different breast reduction techniques, and each has its pros and cons. Your surgeon will have recommendations, but it’s important to be informed.
Vertical, or “lollipop”
Traditional, or “anchor”
The vertical, or lollipop, breast reduction technique involves incisions made around the areola and vertically down to the breast crease, creating a shape resembling a lollipop.
The traditional, or anchor, breast reduction technique involves three incisions: around the areola, vertically down to the breast crease, and horizontally along the breast crease, resembling an anchor shape.
By evaluating your goals with surgery and the pros and cons of the above procedures, you can get a better idea of the type of breast reduction you’re looking for to help guide you as you start your search for plastic surgeons.
Search for Providers With Expertise
You can start by making a list of plastic surgeons who provide breast reduction surgery in your area and then narrow it down based on their expertise, resources, and results. For example, if you require a traditional (anchor) breast reduction surgery, you will want to search for a surgeon who has extensive experience with that technique.
Plastic surgeons will typically list their areas of specialty on their websites. Some breast reduction surgeons will handle both types of surgeries; others prefer to handle less complex vertical cases. Take some time to review their website, their before and after pictures, and their services to see where their strengths lie.
Look for an Office With an Insurance Coordinator
The title may be different depending on where you go, but the job duties are the same. This person works specifically with your insurance company, negotiating and gaining pre-authorization to minimize your out-of-pocket costs. They essentially become your representative with the insurance company, helping you get the treatment you need.
Schedule a Consultation
The only real way to know if a breast reduction surgeon is right for you is to schedule a consultation that allows you to vet the bedside manner of that plastic surgeon. They should listen to your concerns with compassion, go over your goals and your medical history, and discuss your surgical options with you. Some offices will even use advanced technology to show you what results you can expect with the surgery. During this consultation, you should get a detailed surgical plan that you can take to their insurance coordinator who will help guide you through the process.
That is how you find the best breast reduction surgeon for your insurance. You can do your due diligence online, but that will only take you so far. Getting into the surgeon’s office will help you determine: (1) if surgery is right for you, and (2) if they’re the right person to complete it. You’ll also be able to get a good idea of what your expected out-of-pocket expenses will be so there are no financial surprises later on.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
Harris Plastic Surgery is one of the best breast reduction surgeons for patients needing medically necessary reduction mammoplasty. To learn more, contact us for a consultation.
Joanne Parrinello, Practice Manager
Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.