Does Insurance Cover Breast Reduction?

Breast reduction surgery is often anything but cosmetic. It is a procedure that removes skin, fat, and glandular tissue from the breasts. Breast reduction makes the breasts smaller, lighter, and firmer, and can also be performed to reduce areola size.

This procedure, also known as reduction mammaplasty, is indicated for the treatment of symptomatic macromastia (large breasts). The commonly reported symptoms related to macromastia are neck, shoulder and back pain caused by the weight of overly large breasts upon the musculoskeletal system. Other secondary symptoms can include breast pain and dermatitis or rashes beneath the breasts.

While all of these symptoms might be present in a woman with large breasts, reduction mammaplasty may not immediately be covered by your health insurance. However, this doesn’t mean that it won’t be covered. Patients just need to take a few steps on their own to make sure their health insurance plan covers their breast reduction surgery.

On its face, insurance companies classify breast reduction surgery as a cosmetic procedure. This is largely because insurance companies require proof of an adequate number of health issues due to large breasts and attempted remediation of those issues prior to undergoing corrective surgery.

Attempted remediation can be many things. Largely, attempted remediation simply means that you have gone to several experts about your symptoms. For example, a woman experiencing negative or painful symptoms due to her large breasts might go to a physical therapist, a chiropractor, an orthopedic consultation, or a dermatologist before requesting insurance coverage for breast reduction surgery.

Why Should I Go to Several Health Experts?

While going to all of these separate health experts for the same issue may seem counterintuitive, it’s actually essential to receiving health insurance coverage for your breast reduction surgery. In their eyes, some women may only want to reduce their breast size for cosmetic reasons, so they leave it to the patient and the patient’s doctors to prove medical relevancy.

It’s on the patient to prove to the person reviewing an insurance claim that receiving this surgery will benefit your health in a meaningful way. This might mean having a chiropractor or physical therapist recommending the surgery to reduce or remove back or neck pain. It may also mean seeing a dermatologist to recommend the surgery to treat/remove rashes underneath the breasts. It all depends on a patient’s individual symptoms and the severity of those symptoms.

Because many women experiencing negative health side effects view breast reduction as a medical necessity, they may expect the reduction procedure to be automatically covered. Unless the patient is able to provide proof of negative health side effects, insurance providers will likely continue to view it as a cosmetic procedure.

Of course, each individual insurance plan is different and should be consulted before making assumptions about coverage.

What to Do If Insurance Rejects the First Claim

First of all, don’t panic. If an insurance company has decided that it will not cover breast reduction surgery, it is likely because the patient did not provide sufficient evidence of medical necessity.

Before attempting again, exhaust all of your options. Make sure that you have gone to several different medical professionals for opinions and get those opinions documented. When you attempt to get the surgery covered again, having a wide range of medical opinions will help the cause.

Depending on the insurance company, they may also request several months of documented treatment of the symptoms associated with large breasts. Insurance companies want to see that you have tried everything else before stepping in and assisting with payment.

The Bottom Line

If you feel you are a candidate for breast reduction surgery and are requesting health insurance coverage, contact your health insurance provider. Have them send you their criteria for coverage in writing and use that as a baseline for what is needed. Every insurance company has different, independent criteria and indications, so be sure to read closely and speak with your doctor about your options.

There is one thing you can count on; Dr. Siwy is on your side. Dr. Siwy is a native Hoosier, completing her entire education and medical training in her home state of Indiana. She has never left the ethics of the heartland behind and feels that each patient deserves to be treated kindly, honestly and with respect. You can be assured of quality work delivered with the utmost care.

If you have questions about the insurance coverage of a potential breast reduction surgery, give us a call at 317.268.8799.

Siwy Plastic Surgery