Are you considering breast reduction surgery? If so, then you’re probably wondering if your health insurance will cover the procedure.
In this article, we’ll discuss how breast reduction surgery is covered by most major health insurance plans and what to expect after you’ve had the surgery.
Breast Reduction Surgery Insurance Coverage United Healthcare
When Does Insurance Cover Breast Reduction Surgery?
- Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary.
- Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary.
- To get insurance coverage, you’ll probably need documentation of chronic health issues due to breast size.
Very large breasts — sometimes called macromastia — can cause health problems. The weight of the breasts may lead to pain in the back, shoulder, and neck. Some women have permanent shoulder grooves caused by bra straps or recurrent rashes under the breasts.
Breast reduction surgery — also called reduction mammoplasty — can not only remedy physical symptoms like these but also have psychological benefits. It can improve people’s quality of life, self-esteem, and body image.
If you’re considering a breast reduction, you’re probably wondering how much it costs and whether health insurance covers it. Breast reduction surgery for cosmetic reasons doesn’t qualify for coverage. But if you’re getting the surgery for medical reasons, your health insurance may well cover it. Your insurer has specific rules for how you can get coverage for a breast reduction.
Read on for more details about the cost of breast reduction surgery and when insurance will pay for it.
Is breast reduction covered by health insurance?
It depends. Health insurance only covers breast reduction if it’s considered medically necessary to treat chronic health symptoms.
This means that before you can schedule the breast reduction surgery, you’ll probably have to get insurance authorization. The insurance company will require your surgeon to submit certain health records on your behalf; it will then assess your medical need for the surgery. (Even if your insurance does cover the surgery, you’ll still have to pay copays or deductibles.)
If your breast reduction surgery doesn’t meet your health plan’s medical necessity criteria, it will be considered cosmetic, meaning the insurance company won’t cover it.
How to get a breast reduction covered by insurance
Getting approval for breast reduction surgery can be a long, complicated process. Insurers have different criteria for judging the surgery as medically necessary.
Your health insurance plan may require:
- A physician’s letter detailing your health symptoms and how long you’ve had them
- Medical records of previous treatments you’ve tried
- Your height and weight
- Photos of your breasts
You’ll generally have to provide records showing that:
- You have chronic health symptoms caused by having large breasts
- You have tried other, nonsurgical treatments
- The nonsurgical treatments have not helped
Some insurers have required a person to be within 20% of their ideal body weight before approving coverage, as weight loss alone can cause the breasts to become smaller. However, this requirement has been questioned by some surgeons and academics, given that lasting weight loss is difficult and sometimes unrealistic.
Your best bet is to contact your insurer as early as possible, and ask them to list and explain all the requirements and what forms of proof they will accept. That way, you’ll know exactly what documentation to gather and submit.
What makes a breast reduction medically necessary?
A doctor must determine that the surgery is medically necessary. You may need to provide evidence to the doctor and insurer that you’ve already tried nonsurgical treatments — such as physical therapy, weight loss, or musculoskeletal treatments — without success. The insurance company may want proof that you’ve had symptoms for at least 6 months.
Insurance companies may approve breast reduction surgery as medically necessary if:
- You have severe rashes or skin infections that are hard to treat.
- Your physical activities are restricted.
- You have nerve compression due to the weight of the breasts.
- The weight of your breasts is significantly affecting your posture and spine alignment.
- Your breasts are painful.
- You have upper-back, neck, or shoulder pain.
- You have shoulder grooves from bra straps.
Do breasts have to be a certain size in order for you to be a candidate for reduction?
When it comes to reduction surgery, it’s not exactly a matter of how large your breasts are. The main measure is the amount of tissue to be removed. Your insurance company’s “medically necessary” criteria may require that the procedure remove a certain minimum amount of tissue.
Some insurers use the Schnur Sliding Scale as a reference. This is a ratio that compares the weight of the removed breast tissue with your total body surface area. Although this calculation is a common guideline, it’s not always an absolute rule.
Typically, if your Schnur ratio is above the 22nd percentile, your surgery is considered medically necessary. If it’s below the 5th percentile, it’s considered cosmetic. If your ratio is in between, it may be considered either medical or cosmetic, or a mix of both, and may or may not be approved by insurers.
How much weight is removed in breast reduction?
The minimum amount varies according to your insurance carrier’s definition. For some, if the amount of breast tissue removed is less than 200 to 350 grams (7 to 12 ounces), the procedure may be considered a breast lift rather than a breast reduction. A breast lift is typically considered cosmetic surgery, and so it is not covered by insurance.
Does Medicare pay for breast reduction?
Not always. Like private insurers, Medicare doesn’t cover cosmetic breast reduction surgery. Both original Medicare and Medicare Advantage will cover the procedure when it is determined to be medically necessary. However, you will probably have to pay for a deductible, copay, or coinsurance.
How much does a breast reduction cost with insurance?
The total cost of breast reduction surgery has several components, including:
- Surgeon’s fee
- Anesthesia fees
- Hospital costs
- Medical tests
- Post-surgery garments
- Prescription medications
The average plastic surgeon’s fee for breast reduction was $5,717 as of 2020, according to the Aesthetic Plastic Surgery National Databank. But fees vary significantly depending on factors like:
- The surgeon’s level of experience
- What breast reduction technique the surgeon uses
- Whether you have the surgery on one or both breasts
- Market pricing in your geographic location
For example, according to estimates from FAIR Health, here’s a cost breakdown for a patient in Columbus, Ohio, with commercial insurance.
|Surgeon’s fee||$4,782 ($2,391 per breast)|
|Facility cost for ambulatory surgical center||$6,548|
|Facility cost for hospital outpatient||$10,257|
|Total||$12,327 at an ambulatory surgical center|
$16,036 at a hospital as an outpatient
Not included: Possible costs such as medical tests, post-operative recovery garments, prescription medications, follow-up treatment, or other fees.
How much does breast reduction surgery cost for the uninsured?
Without insurance, that patient in Columbus, Ohio, would face costs like this, according to FAIR Health:
|Surgeon’s fee||$15,870 ($7,935 per breast)|
|Facility cost for ambulatory surgical center||$16,582|
|Facility cost for hospital outpatient||$20,179|
|Total||$34,603 at an ambulatory surgical center|
$38,200 at a hospital as an outpatient
How can I finance a breast reduction?
Numerous plastic surgery providers offer medical financing options, including payment plans. Many accept CareCredit, a healthcare credit card. CareCredit has promotional plans that feature no-interest financing if you pay in full within a given period (6 to 24 months). If you don’t, however, interest charges kick in — potentially at the high annual percentage rate (APR) of 26.99%.
Some online lenders offer loans that can be used to pay for plastic surgery. For example, Prosper Healthcare Lending loans have interest rates ranging from 7.95% to 36.00% APR for up to 60 months.
Of course, you don’t have to use a loan or credit card marketed specifically for healthcare to finance a breast reduction. You can use savings, or shop around to get the lowest-rate loan or credit card available to you. The national average APR on credit cards is less than 15%.
What to expect after breast reduction surgery
After breast reduction surgery, you may need to take a week or two at home to rest and recover. You’ll have some appointments with your plastic surgeon to remove your sutures and get follow-up care. It may be a month or more before you can exercise or do any strenuous activity.
What are the potential complications of breast reduction surgery?
Like any other major surgery, breast reduction surgery has risks. These can include:
- Adverse reaction to anesthesia
- Loss of sensation in the breasts or nipples
- Difficulty or inability to breastfeed
- Asymmetric breasts, potentially requiring additional surgery
Even if your incisions heal without mishap, the results might not turn out looking exactly as you envisioned or as your surgeon planned. This is a risk with any type of plastic surgery.
The bottom line
Breast reduction surgery is covered by health insurance when it’s medically necessary. Proving the medical necessity to your insurer can be complicated and may require a lot of documentation from your healthcare provider. Uninsured people, or those who want the reduction for aesthetic reasons, will have to pay for it entirely out of pocket.