breast reduction surgery is performed to reduce the size of the breasts. sometimes surgeons perform the procedure to treat physical or psychological symptoms caused by having large breasts, and other times the surgery is done for purely cosmetic reasons.
According to the American Society of Plastic Surgeons, breast reduction surgery costs about $5,193 on average. therefore, you may be wondering if your health insurance policy will cover the cost of your treatment. this article explains if unitedhealthcare covers breast reduction surgery and who is eligible.
Does unitedhealthcare cover breast reduction surgery?
Most unitedhealthcare policies do not cover breast reduction surgery. however, unitedhealthcare may cover breast reduction surgery if it is needed after a mastectomy. Click below to search for Medicare Advantage plans that may provide coverage for breast reduction surgery.
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) stipulates that private and group health insurance plans must cover reconstructive surgeries if they also cover mastectomies.
Therefore, you may qualify for coverage if you need a breast reduction to achieve symmetry after a mastectomy and your plan covers mastectomies. You may also be eligible for unitedhealthcare breast reduction coverage if you need nipple-sparing surgery before having a mastectomy.
However, specific unitedhealthcare plans may cover breast reduction surgery in circumstances not covered by whcra. If your plan includes benefits for breast reduction surgery, your doctor must certify that the treatment is medically necessary and reconstructive.
When is breast reduction surgery medically necessary?
unitedhealthcare may consider a medically necessary breast reduction if you have a condition called macromastia. People with macromastia have breasts that are unusually large compared to body proportions, which can sometimes cause associated health problems. Macromastia must be the primary cause of any functional impairment you hope to resolve through surgery to qualify for coverage. in addition, your doctor must reasonably believe that the surgery will significantly improve any functional impairment.
unitedhealthcare may consider breast reduction surgery medically necessary if you have one or more of the following functional impairments:
- severely raw, itchy, or weeping skin (intertrigo) that does not respond to less invasive treatments
- restriction of daily activities due to problems associated with macromastia
- nerve compression that does not improve with other treatments
- chronic pain in the breasts, upper back, neck, or shoulder
- shoulder grooves caused by bra straps digging in
The above list is not exhaustive. unitedhealthcare may consider covering breast reduction surgery for other reasons on a case-by-case basis, as long as they qualify as medically necessary and reconstructive.
When is breast reduction surgery reconstructive?
Whether you qualify for unitedhealthcare breast reduction coverage also depends on the amount of tissue your surgeon recommends removing. unitedhealthcare determines eligibility based on the amount of tissue removed using the schnur chart. This graph measures how much tissue is removed per breast compared to the total body surface area to indicate whether the surgery is reconstructive or cosmetic.
if you have a covered functional impairment, your surgery counts as reconstructive if the amount of tissue to be removed exceeds the 22nd percentile. unitedhealthcare considers the surgery cosmetic if the amount falls below the 5th percentile. determines eligibility for members who rank between the 5th and 22nd percentiles based on a review of the medical evidence.
unitedhealthcare breast reduction exclusions
Most unitedhealthcare policies specifically exclude breast reduction surgery unless it is included in the whcra. all unitedhealthcare plans exclude breast reduction surgery performed for cosmetic reasons.
A breast reduction is generally considered cosmetic if it does not correct a functional impairment or does not meet the criteria for being medically necessary and reconstructive. unitedhealthcare does not cover breast reductions where liposuction is the only tissue removal method used, even if the beneficiary meets the other eligibility criteria.
unitedhealthcare policies will not cover breast reduction surgery to correct macromastia caused by a congenital anomaly, unless the enrollee also experiences a functional impairment. psychological symptoms associated with macromastia do not count as a functional impairment, and thus will not qualify a beneficiary for coverage.
what medical evidence does unitedhealthcare require for breast reduction surgery?
unitedhealthcare requires medical documentation to determine if an enrollee is eligible for breast reduction coverage. this documentation must include the beneficiary’s weight, height, and breast size and include photographs if she has a diagnosis of macromastia.
Medical notes should describe the reasons why a breast reduction is being sought and a detailed description of associated functional impairments. The doctor should also list any tests performed to rule out alternative causes, as well as details of any less invasive treatments that have been tried to improve any functional deficiencies.
unitedhealthcare also requires details of the proposed surgery. These details should include the amount of tissue the surgeon intends to remove per breast.