The college student was referred to me by her gynecologist and arrived with a prescription recommending a consultation with a plastic surgeon due to her condition. The patient was under the common impression that because she was referred to me by another physician, that the suggested surgery would automatically be covered by her health insurance plan. She came in hoping that the breast reduction surgery could be scheduled in four weeks, during her winter break from college.
After completing a patient history and regional breast examination, my staff discussed with her what would be needed to obtain insurance authorization for her surgery.
How much does insurance cover breast reduction
As it turned out, this patient had no other medical treatment or previous consultations concerning her macromastia. She also had no history of being referred for physical therapy, chiropractic treatment, an orthopedic consultation or a dermatology exam. For many procedures, this lack of treatment history might not be an issue. But for breast reduction, which can be considered cosmetic or reconstructive, depending on the patient – and the insurance company reviewer – the lack of history for this patient would prove problematic.
Unfortunately, the patient had not completed all of the regimens that her insurance required for the reduction procedure to be covered in her case. She will be able to reapply for reduction mammoplasty coverage after the requirements have been completed, but, unfortunately, there is still no guarantee that her insurance will cover the procedure. Naturally, as a college student, she was not in the position to consider paying out-of-pocket for the procedure and was not happy to discover the insurance hurdles she would need to go through for potential coverage.
This story is just an example of why it’s so important for patients to do their homework regarding their insurance coverage for any surgical procedure before seeing a surgeon. The answer to “is breast reduction surgery covered by health insurance?” can be very complicated and involve many variables.
Breast reduction and health insurance
It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure.
In the case of breast reduction, however, for insurance purposes, it will typically be considered a cosmetic procedure until the patient can prove an adequate number of health issues and attempted remediations of those issues prior to undergoing corrective surgery. Once the threshold has been reached, the insurance company may then consider breast reduction a reconstructive procedure for that patient and cover it. The problem is that the threshold can be different for every insurance company or insurance company reviewer. It is my opinion that breast reduction surgery has long been thought of as a “hybrid” procedure. It is considered reconstructive in attempts to obtain insurance coverage for the surgery, but it is also considered cosmetic in that patients expect meticulous aesthetic expertise in their surgery and results.
In our practice, it has become increasingly difficult to obtain insurance coverage for breast reduction surgery. Insurance companies frequently require 2-3 documented reports from other referred specialists before they’ll consider covering it. Also, the insurance companies commonly request 6-12 months of documentation and treatment by either a physical therapist, chiropractor, dermatologist or orthopedist.
What does this mean for a patient who needs the procedure due to chronic health problems caused by macromastia? Keep yourself updated on policies during this process, as the insurance company’s criteria are this year might not be the same next year.
If you feel that you are a candidate for breast reduction surgery and are requesting coverage under your health insurance, it is important that you contact your health insurance carrier and have them forward to you in writing their criteria for coverage. Every insurance company has different, independent criteria and indications. While your neighbor down the street may qualify for the procedure via one insurance carrier with a seemingly less severe situation, you may not be given the same answer by yours. On average, it takes between 3-6 months of preparation, including secondary consultations with other healthcare providers and possible therapy (physical therapy or chiropractics) to qualify for insurance coverage for breast reduction.
How do you handle this? Notify your primary care physician as soon as possible concerning any symptoms which may be related to your macromastia. It is never too early to start the process. Please contact your plastic surgeon’s office with any questions you might have that relate to breast reduction surgery and coverage through your health insurance and they can try to help guide you through the process, so that you can obtain the care you need.
When Does Insurance Cover Breast Reduction Surgery?
Key takeaways:
- 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.
| Item | Price |
|---|---|
| Surgeon’s fee | $4,782 ($2,391 per breast) |
| Anesthesia fee | $997 |
| Facility cost for ambulatory surgical center | $6,548 |
| Facility cost for hospital outpatient | $10,257 |
| Total | $12,327 at an ambulatory surgical center or $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:
| Item | Price |
|---|---|
| Surgeon’s fee | $15,870 ($7,935 per breast) |
| Anesthesia fee | $2,151 |
| Facility cost for ambulatory surgical center | $16,582 |
| Facility cost for hospital outpatient | $20,179 |
| Total | $34,603 at an ambulatory surgical center or $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:
- Bleeding
- Infection
- Adverse reaction to anesthesia
- Bruising
- Scarring
- 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.
What size breasts qualify for reduction?
Most people look in the mirror and wish to change something about their bodies and how they look. Most women worry about their breast sizes, especially after pregnancy. A breast reduction surgery can be a life-changing procedure for anyone who wants to reduce their breast size. If you are considering the procedure, you probably wonder what breast size qualifies for a reduction.
WHAT IS A BREAST REDUCTION?
Breast reduction is a procedure that removes fat, excess skin, and tissues from the beasts to reduce their size. The surgery, also called a reduction mammoplasty, is popular among women and men.
Most females opt to do it to achieve proportional contours, lose weight, and relieve their back pain. Men who do a reduction mammoplasty do it to treat gynecomastia. The medical condition occurs when the male breast tissue swells. It often occurs due to weight gain, aging, puberty, medications, or conditions responsible for inadequate testosterone or too much estrogen in men.
CANDIDATES FOR A BREAST REDUCTION
The best candidates for breast reduction surgery are adults and adolescents with no heart conditions or diabetes and who do not smoke. They should not want reverse gynecomastia. They should also not be obese.
Women fit for breast reduction surgery should relate to the following:
· Nerve pain.
· Restricted activity due to their breast size.
· Poor self-image because of their breasts.
· Difficulty fitting clothing and bras.
· Rash or chronic skin irritation beneath the breasts.
· Chronic shoulder, back, and neck pain that requires medication.
WHO DOES NOT QUALIFY FOR A BREAST REDUCTION?
Experts recommend that patients hold off getting a breast reduction if they are still planning to have children or lose weight. Research shows that the procedure cannot affect your breastfeeding ability because it does not separate the underlying tissue from your nipple. However, you will experience hormonal fluctuations during pregnancy. As a result, your breast size will increase.
You may need a follow-up surgery if you get a breast reduction before finishing getting children to achieve the proportions and contour you desire.
Losing weight has no risk factors after getting a breast reduction. However, it is vital to understand that fatty tissue deposits make most of your breast, not glandular tissue. Consequently, weight loss through exercise and diet will reduce the size of your breasts. Reduction mammoplasty may be necessary to reduce the breast more.
HOW TO PREPARE
Your specialist will assess your health and take and review your medical history during your first consultation. They will do so to make sure you are healthy enough to have the procedure. They will also discuss your expectations for the breast size and appearance after the reduction. Doing so is vital to ensure what you expect is realistic.
You can bring pictures of what you think you want to make it more helpful. Your plastic surgeon can determine if the surgery would be suitable and if your breasts are proportionate with your contours, like the hips and waist. Once your specialist determines that breast reduction surgery is ideal for you, they will measure and examine your breasts. They will also photograph them to keep as part of medical records.
WHAT SIZE QUALIFIES FOR A BREAST REDUCTION
Most surgeons do not dictate or require a particular size to qualify you as a candidate for breast reduction. The most vital factor they consider is if the breast size causes you mental and physical health problems.