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Is breast reduction covered by health insurance? | ASPS

I recently saw a college student as a new patient consulting my office about possible breast reduction surgery. This procedure, also known as reduction mammoplasty, is indicated for the treatment of symptomatic macromastia (large breasts). Commonly reported symptoms related to macromastia are neck, shoulder, and back pain caused by the weight of oversized breasts on the musculoskeletal system. other secondary symptoms may include sore breasts and dermatitis or rashes under the breasts.

The college student was referred to me by her gynecologist and came with a prescription recommending a consultation with a plastic surgeon due to her condition. The patient was under the common impression that because another doctor referred her to me, the suggested surgery would automatically be covered by her health insurance plan. She arrived hoping that breast reduction surgery could be scheduled in four weeks, during her winter break from college.

Reading: How can i get insurance to pay for breast reduction

After completing a patient history and regional breast exam, my staff discussed with her what it would take to obtain insurance authorization for her surgery.

It turned out that this patient had no other medical treatment or previous consultations regarding her macromastia. neither did she have a history of being referred for physical therapy, chiropractic treatment, orthopedic consultation, or dermatological examination. for many procedures, this lack of treatment history may not be a problem. but for breast reduction, which may be considered cosmetic or reconstructive, depending on the patient, and the insurance company reviewer, this patient’s lack of history would be problematic.

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Unfortunately, the patient had not completed all of the regimens her insurance required for the reduction procedure to be covered in her case. she will be able to re-apply for reduction mammoplasty coverage after the requirements have been completed, but unfortunately, there is still no guarantee that her insurance will cover the procedure. Naturally, as a college student, she wasn’t in a position to consider paying out of pocket for the procedure and she wasn’t happy to discover the insurance hurdles she would have to overcome to obtain possible coverage.

This story is just one example of why it is so important for patients to research their insurance coverage for any surgical procedure before seeing a surgeon. the answer to “is breast reduction surgery covered by insurance?” can be very complicated and involve many variables.

breast reduction and health insurance

Patients universally believe that if surgery is considered reconstructive, it is medically indicated and covered by health insurance. conversely, many patients believe that if a procedure is considered cosmetic, it is not a medically indicated or covered procedure.

however, in the case of breast reduction, for insurance purposes, it will generally be considered a cosmetic procedure until the patient can demonstrate an adequate number of health problems and attempts at remediation of those problems prior to undergoing to corrective surgery. once the threshold has been reached, the insurance company may consider breast reduction a reconstructive procedure for that patient and cover it. The problem is that the threshold may be different for each insurance company or insurance company reviewer. In my opinion, breast reduction surgery has long been considered a “hybrid” procedure. it is considered reconstructive in attempts to obtain insurance coverage for the surgery, but it is also considered cosmetic in the sense that patients expect a meticulous aesthetic experience in their surgery and results.

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In our practice, it has become increasingly difficult to obtain insurance coverage for breast reduction surgery. insurance companies often require 2-3 documented reports from other referred specialists before they will consider covering you. Additionally, insurance companies commonly require 6-12 months of documentation and treatment by a physical therapist, chiropractor, dermatologist, or orthopedist.

What does this mean for a patient who needs the procedure due to chronic health problems caused by macromastia? Stay up-to-date on policies during this process, as the insurance company’s judgment is that this year may not be the same as next year.

If you think you may be a candidate for breast reduction surgery and are applying for coverage under your health insurance, it is important that you contact your health insurance company and have their coverage criteria sent to you in writing. each insurance company has different and independent criteria and indications. while your neighbor down the street may qualify for the procedure through an insurance company with a seemingly less serious situation, yours may not give you the same answer. On average, it takes 3-6 months of preparation, including secondary consultations with other health care providers and possible therapy (physical therapy or chiropractic) to qualify for breast reduction insurance coverage.

how do you handle this? notify your primary care physician as soon as possible of any symptoms that may be related to your macromastia. It’s never too early to start the process. Please contact your plastic surgeon’s office with any questions related to breast reduction surgery and coverage through your health insurance and they can try to guide you through the process, so you can get the care you need.

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