Will Insurance Cover Breast Reduction?

June 17, 2018
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When considering cosmetic surgery, insurance coverage is one of the most common concerns and is often the deciding factor in choosing whether or not to undergo surgery. If you want a breast reduction surgery, you're probably wondering whether your healthcare providers will cover the procedure. 

Cosmetic vs Medically Necessary Breast Reduction

Most health insurance plans don't cover any cosmetic surgeries, but they will cover reconstructive surgeries and medically necessary procedures. In some cases, a breast reduction is done for cosmetic purposes. You may feel self-conscious about your breast size and choose to undergo a reduction to increase your confidence in your figure. 

In other cases, breast size is linked to physical health issues, and surgery may be necessary to fix these problems. Many women have chronic back and neck pain because of their overly large breasts. Chronic pain can limit your mobility and seriously impact your quality of life. Large breasts often lead to poor posture, and this combined with the weight of the breasts can cause nerve damage, leading to numbness in the arms, hands, and fingers. 

Another common problem is rashes, infections, or inflammation underneath the breasts. Large breasts tend to trap moisture and heat, which can cause painful skin issues. Some women also develop permanent shoulder grooves where their bra straps sit because their breasts are too heavy for a bra to fully support. 

Other serious issues associated with a large breast size include exercise intolerance, shortness of breath, and chronic headaches. If you experience these symptoms, it's clear that a breast reduction is necessary to restore your health. Most insurance plans use these symptoms to differentiate between cosmetic and medically necessary breast reductions. However, it can still be complicated to have the surgery covered. 

How to Know If Your Insurance Will Cover Your Breast Reduction

The first thing you need to do is check if your health insurance lists breast reduction as an exclusion. If it does, your insurance will not cover the surgery. Fortunately, most insurance plans do not have an exclusion for breast reduction. This doesn't mean that they'll cover all breast reduction surgeries, but you have a chance of getting the procedure covered. 

Most insurance plans require that a certain amount of tissue be removed for the surgery to be covered. If less than this specified amount is removed, they believe that the breasts were not large enough to cause pain or health problems and that the surgery was only done for cosmetic purposes. 

The amount of tissue that needs to be removed varies based on the insurance company and plan. Some plans take your height and weight into consideration, and some specify an exact amount for everyone. Many insurance companies require that the surgery remove at least 500 grams of tissue to be covered. 

How to Get Your Breast Reduction Covered

If you believe that your insurance might cover your breast reduction, there are a few steps you should take. First, start documenting your symptoms. If you experience back or neck pain, posture issues, numbness, skin irritation, or any other problems because of your breast size, you should record when the symptoms started and whether they've progressed over time. 

If you've seen other medical professionals for these problems, try to get documentation of your visit. This includes massage therapists, physical therapists, and chiropractors. You should also document other treatments you've tried for the health problems. Many insurance plans require that you try other treatments before surgery, so keeping track of everything you've tried to reduce your pain will be very helpful. 

Once you have some documentation of your symptoms, it's time to schedule a consultation with a cosmetic surgeon. Your surgeon can identify posture issues or other problems and may diagnose you with symptomatic macromastia, which is the medical term for overly large breasts that cause chronic pain and other problems. This diagnosis is key for getting your insurance to cover the surgery. 

If your surgeon believes that your breasts are affecting your health, you can then reach out to your insurance company and request coverage. You and your surgeon will fill out paperwork and submit it to your insurance company, and they will hopefully approve the surgery. If they deny coverage, you can make an appeal. During this process, you'll have to supply extra documentation to your insurance company. You can get letters of support from other medical professionals, and your surgeon can give more information to your provider. 

All insurance plans are different, and some will cover breast reduction more willingly than others. If you want the surgery only for cosmetic reasons, it's unlikely that it will be covered. If you have documented health problems resulting from your breast size, you have a better chance. It can be time-consuming work to convince your insurance company to cover the surgery, but it's worth it to improve your quality of life. 

The doctors at the Plastic Surgery Institute of Miami provide breast reduction along with a wide variety of other procedures. Dr. Altman completed the prestigious Jerome P. Weber Fellowship before founding the Plastic Surgery Institute. Dr. Ghersi served as a faculty member in the plastic surgery department of the renowned Cleveland Clinic and completed an exclusive fellowship at the Manhattan Eye, Ear, and Throat Hospital. Dr. Oeltjen was an Associate Professor of Plastic Surgery at the University of Miami before entering private practice. You can learn more about these doctors and their services here: www.psimiami.com.

This is a guest post.

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