How to get a breast reduction covered through insurance

Extremely large, disproportionate breasts and breast tissue, also known as macromastia, is a serious issue for many women. Macromastia can interfere with many basic functions, such as sitting or standing properly, exercising, and sleeping. The excess tissue pulls on your back and shoulders, causing tenderness, pain, swelling, poor posture, and difficulty lifting.

Macromastia is a medical condition. Some forms of macromastia can be addressed through non-surgical treatments. However, some forms can only be remedied by reduction mammaplasty, or breast reduction. In many cases, breast reduction can relieve many of the symptoms of macromastia, giving women the freedom to move and do as they please.

How to Get a Breast Reduction Covered by Insurance

If you are considering having a breast reduction procedure, you are probably aware of the financial burden of the procedure. You should begin by reading your insurance policy. Some insurance policies come with mammaplasty exclusions, which means that you might not have coverage for a mammaplasty consultation with a physician. If this isn’t the case, the next step will be to set up a consultation with an aesthetic-and-reconstructive surgeon.

Preauthorization

Most insurance providers will want you to get preauthorization for a breast reduction procedure. Depending on your insurance provider, this will involve getting a recommendation from your surgeon that you are a good candidate for reduction mammaplasty. Your surgeon will take photos of your breasts and breast tissue. These pictures will be sent to a board of doctors and surgeons who work for the insurance company. This board will review your medical history and current information in order to determine if breast reduction is medically necessary in your case. A variety of factors, such as your height, weight, breast size, and weight of the breast tissue will be used to determine if you will receive insurance for breast reduction.

In the Event of an Initial Rejection

If your insurance provider initially rejects your coverage, saying that the breast reduction is cosmetic, there is still a possibility that you could get coverage. You have a right to appeal the provider’s findings. Have your surgeon contact the insurance company and explain why you are a good candidate for the procedure. Letters of support from other medical professionals, therapists, and family members can also help. Up-to-date insurers will have the latest literature available on mammaplasty, but some insurance providers use older, outdated methods to determine if patients qualify for insurance for breast reduction.

Authorization

Once your authorization comes through from the insurance company, you can schedule the breast reduction with your surgeon. With most insurance coverage, you will only be responsible for the co-pay for the procedure. Co-pay for treatment in a hospital or similar facility ranges from $100 to $300. This is much cheaper than paying the full price of the breast reduction!

In the United States, the average size of a woman’s breasts has steadily increased in the last four decades, rising from a 34B in 1983 to a 34DD in 2013. While a larger cup size can be appealing for many people, for women whose breast size is disproportionate to the rest of their body, it can cause serious health complications. In some cases, weight loss can decrease your cup size, but in others, the only option is breast reduction surgery.

Discover why you might need a breast reduction procedure and whether private health insurance covers the cost of surgery.

Why You May Need a Breast Reduction

A breast reduction, also called a reduction mammaplasty, is a surgical operation to remove excess breast tissue, fat, and skin to decrease your cup size. Many women opt for a breast reduction due to the adverse effects large breasts have on their health. Some common issues caused by overly large breasts include:

• Neck, back, and shoulder pain
• Rounded shoulders (kyphosis)
• Poor posture
• Shoulder grooves due to breast straps digging in and rubbing because of inadequate bra support
• Numbness in the chest, arms, and fingers due to nerve compression
• Problems breathing, especially in a prone position and while sleeping
• Skin rashes and infections; the fold beneath the breast tissue provides an optimal environment for bacterial growth
• Migraines

Men can also undergo breast reduction surgery if they suffer from gynecomastia – enlargement of the breast tissue – which is often due to hormonal disruptions.

How Much Does a Breast Reduction Cost?

According to the American Society of Plastic Surgeons, the average cost of reduction mammaplasty is approximately $5,900 as of 2020. This price includes the board certified plastic surgeon’s fee, hospital fees, medical and diagnostic testing, surgical and post-surgical garments, and prescription medications. This does not include the cost of anesthesia.

The surgeon’s fee differs depending on their level of experience and expertise, the types of surgical techniques they use, and their practice location. Your surgeon can give you a quote for the final cost of the procedure, so you can obtain authorization from your insurance company to go ahead with the surgery.

Does Insurance Cover Breast Reduction?

Most insurance carriers offer full or partial coverage for breast reduction surgery, as long as it meets the criteria that deem it a medical necessity. Major insurance companies, including Aetna, Cigna, and United Healthcare, consider a breast reduction to be cosmetic unless it causes symptoms such as paresthesias (numbness and tingling), ulceration, significant pain, or persistent rashes.

For an insurance carrier to cover the procedure, you must prove that you have attempted to address these issues using other means, such as medication or physical therapy. If you can prove that it is medically necessary, the carrier may categorize the procedure as reconstructive rather than cosmetic and offer insurance coverage.

How Do You Get Insurance to Cover Breast Reduction Surgery?

There are several steps you need to take to get insurance to cover breast reduction surgery, including:

Pre-authorization

If you have a comprehensive insurance plan that includes coverage for a breast reduction, you’ll need to provide documentation to prove that it is medically necessary to get pre-authorization.

You’ll need to provide medical records from licensed physicians demonstrating that you have experienced physical complaints and attempted conservative interventions before you can schedule your surgery. These documents may need to date back 6 to 12 months.

Some of the doctors you may need to obtain notes from include your OB/GYN, primary care doctor, orthopedic surgeon, or physical therapist. Most plastic surgeons also recommend that you provide documentation of any complementary alternative medicine (CAM) therapies, such as an acupuncturist or chiropractor.

At your initial breast reduction consultation, your doctor may take photographs of your pre-operative breasts as evidence for the insurance company. They can also provide you with a note documenting the symptoms that lead you to seek a breast reduction.

The documentation is reviewed by a panel of medical professionals that work for the insurance company to assess your medical history and determine if breast reduction surgery is medically necessary in your case.

Initial rejection

According to the AARP, up to 14% of all insurance claims are initially rejected. But that doesn’t mean you can’t get coverage for your breast reduction surgery. You can appeal the rejection. Have your surgeon write a letter to the insurance board explaining why you are a suitable candidate for the surgery. You can also obtain letters of support from other medical professionals to help your case.

Authorization

Once your documentation is accepted, and the insurance company gives their authorization, you can book your breast reduction surgery. Most insurance companies require you to co-pay for a stay at a hospital or medical facility, which can cost from $100-$300.

Visit A Fitting Experience Mastectomy Shoppe for Post Surgical Garments

If you need breast reduction garments to support your chest after surgery, visit A Fitting Experience Mastectomy Shoppe to explore our range of compression bras and vests.

Our staff can also directly bill your insurance provider to help get your claim started. Simply use our HIPAA-compliant online portal to fill out the paperwork.

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