Does Insurance Cover Breast Reduction? Here’s What You Should Know

Does insurance cover breast reduction
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Breast reduction surgery is usually carried out for different purposes. While some are medically related, others are for purely cosmetic reasons. Now the question is, does medical insurance cover breast reduction surgery? We’ll try as much as we can to answer this question in this article, including whether insurance will cover breast reduction surgery for cases like back pain or other medical cases. 

Does Insurance Cover Breast Reduction?

It all depends. Health insurance will only cover breast reduction if it is deemed medically required to alleviate chronic health issues.

This means that you will most likely need to obtain insurance authorization before scheduling the breast reduction surgery. The insurance company will request that your surgeon provide specific health records on your behalf; the insurance company will then evaluate your medical need for the procedure. (Even if your insurance covers the surgery, you will still be responsible for copays or deductibles.)

If your breast reduction surgery does not match the medical necessity criteria of your health plan, it will be considered cosmetic, which means the insurance company will not cover it.

Health insurance and Breast Reduction

Patients generally think that if a surgery is deemed reconstructive, it is medically required and covered by health insurance. In contrast, many patients assume that if an operation is deemed cosmetic, it is neither medically needed or covered.

However, for insurance purposes, breast reduction is often considered a cosmetic procedure until the patient can demonstrate an adequate number of health difficulties and attempts to resolve those issues prior to undertaking corrective surgery. Once the threshold is met, the insurance company may consider breast reduction surgery to be a reconstructive treatment for that patient and cover it. The issue is that the threshold can differ depending on the insurance company or reviewer. It is classified as reconstructive in order to receive insurance coverage for the surgery, but it is also classified as cosmetic in the sense that consumers anticipate thorough aesthetic skill in their procedure and results.

In many clinics, obtaining insurance cover for breast reduction surgery has become increasingly challenging. Before considering coverage, insurance companies often demand 2-3 written reports from other referred specialists. In addition, insurance companies frequently want 6-12 months of paperwork and therapy from a physical therapist, chiropractor, dermatologist, or orthopedist.

What does this entail for a patient who requires the operation because of long-term health issues caused by macromastia? Maintain policy updates throughout this procedure, as the insurance company’s criterion this year may not be the same as next year.

What to do?

If you believe you are a candidate for breast reduction surgery and want to request coverage through your health insurance, you should contact your health insurance company and have them send you their coverage criteria in writing. Each insurance business has its own set of criteria and indicators. While your neighbor down the street may be eligible for the procedure through one insurance carrier due to an apparently less serious scenario, you may not receive the same response from yours. To get insurance to cover your breast reduction surgery, it takes an average of 3-6 months of preparation, including secondary visits with other healthcare specialists and possibly therapy (physical therapy or chiropractics).

How do you deal with this? Notify your primary care physician as soon as possible if you experience any symptoms related to your macromastia. It is never too soon to begin the process. Please contact your plastic surgeon’s office if you have any questions about breast reduction surgery and insurance coverage, and they will try to guide you through the process so that you can get the care you need.

How to Get an Insurance Coverage for a Breast Reduction

Obtaining approval for breast reduction surgery can be a time-consuming and complicated process. Insurers use different criteria to determine whether surgery is medically necessary.

Your health insurance policy may require:

  • A letter from your doctor explaining your health symptoms and the length of time you’ve had them.
  • Medical documentation of past therapies you’ve tried
  • Your stature and weight
  • Images of your breasts

In most cases, you’ll be required to present documentation demonstrating:

  • You suffer chronic health problems as a result of having huge breasts.
  • You’ve tried nonsurgical therapies before.
  • Nonsurgical procedures have not been effective.

Because weight loss alone might cause the breasts to shrink, several insurers have required a person to be within 20% of their optimal body weight before providing coverage. However, given the difficulty and sometimes unrealistic nature of long-term weight loss, some surgeons and academics have questioned this criterion.

Contact your insurance as soon as possible and ask them to list and explain all of the requirements, as well as what forms of proof they will accept. You’ll know exactly what documentation to gather and submit this way.

What Medical Conditions Require a Breast Reduction?

A doctor must decide whether or not the procedure is medically essential. You may need to show the doctor and insurance that you’ve attempted nonsurgical treatments without success, such as physical therapy, weight loss, or musculoskeletal treatments. The insurance provider may need documentation that you have been experiencing symptoms for at least 6 months.

Insurance companies may authorize breast reduction surgery as medically required if the following conditions are met:

  • You suffer from severe rashes or skin infections that are difficult to manage.
  • Your physical activities have been limited.
  • Because of the weight of your breasts, you suffer nerve compression.
  • Your breast weight has a big impact on your posture and spinal alignment.
  • Your breasts are hurting.
  • You are experiencing pain in your upper back, neck, or shoulders.
  • Bra straps have left you with shoulder grooves.

Do your breasts have to be a certain size before you can be considered for reduction?

It’s not just an issue of how big your breasts are when it comes to reduction surgery. The amount of tissue to be removed is the primary metric. The “medically necessary” standards of your insurance company may mandate that the treatment remove a specified amount of tissue.

The Schnur Sliding Scale is used as a reference by some insurers. This is a ratio that compares the weight of the excised breast tissue to the overall surface area of your body. Although this equation is widely used, it is not necessarily an absolute rule.

If your Schnur ratio is higher than the 22nd percentile, surgery is usually regarded as medically required. It is deemed cosmetic if it is less than the fifth percentile. If your ratio falls anywhere in the middle, it may be considered medical, cosmetic, or a combination of the two, and insurers may or may not authorize it.

How much weight is lost during a breast reduction?

The minimum amount differs depending on your insurance company’s definition. Some may choose a breast lift rather than a breast reduction if the quantity of breast tissue removed is less than 200 to 350 grams (7 to 12 ounces). Because a breast lift is considered cosmetic surgery, it is not usually covered by insurance.

Does Medicare Cover Breast Reduction?

No, not always. Medicare, like private insurers, does not cover cosmetic breast reduction surgery. When deemed medically essential, both original Medicare and Medicare Advantage will cover the operation. However, you will almost certainly be required to pay a deductible, copay, or coinsurance.

What is the Cost of a Breast Reduction with Insurance?

Breast reduction surgery costs include numerous components, including:

  • Fee for a surgeon
  • Anesthesia costs
  • Hospital expenses
  • Medical examinations
  • Post-surgery clothing
  • Medications on prescription

According to the Aesthetic Cosmetic Surgery National Databank, the average plastic surgeon’s price for breast reduction in 2020 was $5,717. However, fees vary substantially based on criteria such as:

  • Level of expertise of the surgeon
  • The breast reduction technique used by the surgeon
  • Whether the operation is performed on one or both breasts
  • Pricing on the market in your area

How do I Pay for a Breast Reduction?

Many plastic surgery clinics give medical finance options, including payment plans. CareCredit, a healthcare credit card, is widely accepted. CareCredit offers promotional options that include no-interest financing if you pay in full within a certain time frame (6 to 24 months). If you don’t, interest charges will begin, possibly at the high annual percentage rate (APR) of 26.99%.

Some online lenders provide loans to pay for cosmetic surgery. Prosper Healthcare Lending loans, for example, have interest rates ranging from 7.95% to 36.00% APR for up to 60 months.

Of course, you don’t have to fund a breast reduction using a loan or credit card designed exclusively for healthcare. You can use your money or browse around for the best loan or credit card available. The national average credit card interest rate is less than 15%.

What to anticipate following breast reduction surgery

After breast reduction surgery, you may need to relax and heal at home for a week or two. You’ll have some follow-up appointments with your plastic surgeon to have your stitches removed. You may be unable to exercise or engage in intense activity for a month or longer.

What are the risks associated with breast reduction surgery?

Breast reduction surgery, like any other major surgery, carries hazards. These are some examples:

  • Bleeding
  • Infection
  • Anesthesia-related adverse response
  • Bruising
  • Scarring
  • Sensation loss in the breasts or nipples
  • Breastfeeding difficulty or incapacity
  • Asymmetric breasts, which may necessitate further surgery

Even if your wounds heal without incident, the outcomes may not be exactly as you envisioned or as your surgeon intended. Any form of plastic surgery carries this risk.

Does Insurance Cover Breast Reduction Due To Back Pain? 

If you have huge breasts and suffer from neck, shoulder, or back pain, reduction surgery may be a possibility for you. Unfortunately, because this operation is typically deemed elective, insurance companies will most likely refuse to cover breast reduction insurance on the grounds of back pain.

In Conclusion

Health insurance will typically cover breast reduction surgery under medical conditions, like chronic back pain. Proving medical necessity to your insurer might be difficult and may necessitate extensive paperwork from your healthcare practitioner, but it may well be worth it. In contrast, insurance will not cover your breast reduction surgery on grounds of cosmetic purposes. 

Frequently Asked Questions

What tissues are removed during breast reduction?

Breast reduction surgery often involves raising the nipple and areola and removing excess skin from the lower breast. As a result, breast reduction surgery necessitates an incision around the nipple and areola to relocate them, as well as an incision under the breast to remove excess skin.

Will I have sensation after breast reduction?

Yes, you can maintain sensation around your nipple after breast reduction.

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