Breast reduction surgery, or reduction mammoplasty, can offer significant physical and emotional relief for individuals suffering from the discomfort of having overly large breasts. These discomforts may include chronic back, neck, and shoulder pain, skin irritation, and posture issues.
For many, breast reduction is not merely a cosmetic procedure but a medical necessity to improve overall quality of life. However, the cost of breast reduction surgery can be prohibitive without insurance coverage. Fortunately, many health insurance plans will cover breast reduction if specific medical criteria are met. Read our tips below if you are wondering how to get insurance to cover breast reduction surgery.
How to Get Insurance To Cover Breast Reduction Surgery
The first step in getting insurance to cover breast reduction surgery is to demonstrate that the procedure is medically necessary. Insurance companies typically require proof that the surgery is being sought to alleviate health problems caused by excessively large breasts rather than for cosmetic purposes. Conditions that may qualify for coverage include:
- Chronic pain in your neck, upper back, or shoulders
- Skin conditions, irritation, or infections under the breast crease (intertrigo)
- Nerve pain or numbness in the arms and hands due to breast weight
- Posture issues
- Difficulty exercising or performing everyday activities
- Shoulder grooving or irritation from bra straps
To support your claim of medical necessity, you should keep thorough records of all symptoms and treatments related to these issues. Your healthcare provider should document these symptoms in your medical records, along with any treatments you’ve tried, such as physical therapy, pain medication, chiropractic care, or custom bras, which have failed to alleviate the problem.
Work Closely with Your Surgeon’s Administrative Staff
Choosing an expert board-certified plastic surgeon who has experience handling insurance claims for breast reduction surgery is arguably the most important step in getting your insurance to cover breast reduction surgery. Your surgeon and their support staff will help you gather the necessary documentation to submit to the insurance company.
Documentation Needed For Insurance To Cover Breast Reduction Surgery | |
|---|---|
Proof of Medical Necessity | A letter showing medical necessity from your primary care physician or specialist detailing your symptoms and how they affect your daily life. |
How Surgery Will Help | A description of how the surgery will alleviate these issues. |
Previous Treatments | Records of any non-surgical treatments you have tried and their outcomes. |
Anatomical Photos | Photos of your breasts demonstrate the extent of the problem, which the insurance company typically requires for evaluation. |
Schnur Scale Estimates | An estimate of how much breast tissue will be removed. Some insurance companies require a specific amount of tissue to be removed based on body mass index (BMI) or other guidelines. |
Each insurance company has different guidelines and criteria for covering breast reduction surgery. You should carefully review your insurance policy to understand what is required. You may need to get pre-authorization from your insurance company before undergoing surgery. Without this, you could be responsible for the entire cost.
Additionally, some insurers may require you to meet certain conditions, such as having a minimum amount of breast tissue removed (calculated by the Schnur Scale), a documented history of medical issues related to breast size, or a trial of non-surgical treatments. Be prepared to meet these criteria when submitting your claim.
Understanding Your Insurance Coverage and Appeals Process
If your initial request for coverage is denied, don’t give up. Many insurance companies deny coverage for breast reduction surgery on the first submission, but appeals are often successful. Review the denial letter to understand why your claim was denied, and work with your doctor to provide additional information or documentation that may address the insurance company’s concerns.
One important step in learning how to get insurance to cover breast reduction is to understand all the terminology and details associated with your health insurance. The table below lists some of the main aspects of health insurance and what they mean for your breast reduction coverage.
Insurance Components Affecting Breast Reduction Coverage | ||
|---|---|---|
Term or Phrase | What it Means | Impact on Breast Reduction Coverage |
Medical Necessity | A determination that a service or procedure is needed to treat a medical condition, not for cosmetic reasons. | Insurance will typically cover breast reduction if it can be shown to alleviate medical issues such as chronic pain or posture problems. |
Pre-authorization | Approval from the insurance company before undergoing a medical procedure to ensure coverage. | Breast reduction often requires pre-authorization. Without it, your insurance may not cover the procedure, even if medically necessary. |
Deductible | The amount you must pay out-of-pocket for healthcare before insurance begins to cover expenses. | You must meet your deductible before insurance covers the cost of breast reduction surgery. High deductibles may affect upfront costs. |
Co-payments and Co-insurance | The portion of the surgery cost you are responsible for after meeting the deductible. | Even with insurance coverage, you may still need to pay co-pays or co-insurance for the surgery. These costs vary by plan. |
Exclusions | Services or procedures that are not covered by an insurance plan. | Some insurance policies exclude breast reduction for cosmetic reasons, so proving medical necessity is critical for coverage. |
BMI and Tissue Removal Criteria | Some insurers use BMI or require a minimum amount of tissue to be removed to approve coverage. | If you do not meet the insurer’s criteria (e.g., not enough tissue is removed), your surgery may not be covered. |
Appeal Process | A formal process to request a review of a denied insurance claim. | If your coverage request is denied, understanding the appeal process can help you challenge the decision successfully. |
Work With Harris Plastic Surgery To Make Navigating Insurance a Breeze
Getting insurance to cover breast reduction surgery requires careful preparation and thorough documentation of the medical necessity of the procedure. By working closely with your healthcare providers, understanding the terms of your insurance policy, and submitting a strong case, you can increase your chances of having the surgery covered. If your claim is initially denied, don’t be discouraged—many people successfully appeal and secure coverage for this life-improving surgery.
Harris Plastic Surgery - Your Breast Reconstruction Experts
If you have more questions about how to get insurance to cover breast reduction surgery, contact us online or by phone/text. Or schedule your consultation today.
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.
