Breast Reduction Criteria For Insurance
Breast reduction insurance may be a challenging process as medical necessity is often difficult to prove. All things being equal, the best way to obtain insurance coverage for breast reduction is to make sure you qualify. For instance, if you qualify under your current health plan as having “severe deformity or severe disproportion” of your breasts, it’s likely that an insurance company would approve it based on those conditions alone.
In this guide, we review the aspects of Breast Reduction Criteria For Insurance, what makes a breast reduction medically necessary, breast reduction requirements weight, and is it hard to get insurance to cover breast reduction.
Breast Reduction Criteria For Insurance
Many women know that breast reduction can be an effective way of improving their self-image. However, not everyone is aware that coverage for breast reduction surgery depends on the individual’s health insurance plan. If you’re considering breast reduction, it’s important to understand what conditions you’ll need to meet in order to be approved for this procedure—and how your gynecologist can help you achieve those conditions.
A prior history of breast cancer on either side.
If you have a prior history of breast cancer on either side, your best bet is to talk with a plastic surgeon in your area about reconstructive surgery following the reduction procedure. This is an additional out-of-pocket expense that can be covered by medical insurance as well as Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs), and Health Reimbursement Arrangements (HRAs). The amount of money you’ll pay for this type of surgery will depend on whether or not you’re eligible for reimbursement from your insurance company.
Existence of a lump in either breast.
If you have a lump in either breast, it’s important to see your doctor immediately. Lumps can be cancerous or benign; this distinction is important for determining whether or not breast reduction surgery will be covered by insurance companies. If the lump has been confirmed as benign, you may still need to receive a breast lift or augmentation with implants if your insurance company determines that the excess skin on your breasts makes them saggy and unattractive.
If you wish to avoid having an extra procedure done after having a reduction performed and your insurance company refuses coverage because they do not consider the excessive skin of the breasts to be excessive enough, then there is another option: get yourself insured through Blue Cross Blue Shield of Illinois and go through their appeal process!
Previous radiation treatment to the chest area.
Not surprisingly, breast reduction surgery is not covered by insurance if you have had radiation to the chest area. This makes sense because radiation can cause scarring and tissue damage that could interfere with a successful outcome of your surgery. Also, radiation can also cause a recurrence of breast cancer. While this is rare, it’s another reason why insurance companies won’t cover your reduction procedure if you’ve already had radiation therapy for this same cancerous condition.
For more information about how to pay for breast reduction surgery without health insurance or Medicare coverage, check out our guide here: https://www.medicareadvisorblog.com/how-to-pay-for-breast-reduction-surgery/.
Symptoms of enlarged breasts that cause pain or physical problem.
If you suffer from symptoms of enlarged breasts that cause pain or physical problem, you may be a candidate for breast reduction surgery.
- Pain in the upper back, neck or shoulders: Some women with large breasts have difficulty sleeping because they find that they wake up with sore muscles. This can affect their daily activities as well as cause them to lose sleep at night due to discomfort.
- Pain in the upper chest: Women who have large breasts often describe this feeling as “feeling like my chest is being squeezed” or “having a heavy weight on my chest”. This feeling can also affect how well women sleep and participate in day-to-day activities such as exercising and running errands around town.
- Difficulty sleeping: Some women find it difficult to get comfortable when lying down at night because of their large breasts. They may toss and turn during the night trying different positions before finally falling asleep hours later than usual (or even waking up tired). This lack of quality sleep makes it more difficult for them to function during their day since they are tired most days compared to other people who get enough rest each night!
History of psychological problems related to the breast condition.
Women who have a history of psychological problems related to their breasts are also more likely to be denied coverage for breast reduction surgery. Depression, anxiety and previous trauma relating to the breasts can all be red flags in the eyes of insurance companies. If you’ve had a lot of stress or anxiety about your breasts, talk with your surgeon about ways they can help you cope during this process.
There are also some medical conditions that may affect whether or not you’ll get approved for breast reduction surgery: if you have any type of cancerous growths on your breasts, for example; if there’s been previous breast surgery; or if you’ve experienced a severe infection after an injury near one of your breasts (such as one caused by an IUD).
Signs of infection, signs of tobacco use and symptoms of obesity are also considered when determining eligibility for breast reduction surgery insurance coverage.
If you have signs of infection, such as redness, swelling, and pain in the breasts or underarm area, insurance may not pay for breast reduction surgery.
If you are a smoker and have symptoms of tobacco use such as coughing or wheezing, your insurance company will most likely not pay for breast reduction surgery.
If you have a BMI greater than 35 or if your overall body weight exceeds what is considered healthy for your height (BMI 30–35) then insurance may not cover this procedure.
You need to meet certain criteria for your insurance company to cover your breast reduction surgery.
If you’re wondering about the criteria for breast reduction surgery, you can use a calculator to figure out your costs. You must also meet general health and age requirements.
The calculator lets you input your current symptoms, such as:
- Pain during exercise or activities
- Discomfort while wearing a bra
- Breast size depression (sagging) of more than 1 inch below the inframammary crease (under-breast crease) in either breast when lying down
The calculator will then give you an estimate on how much insurance will cover, including deductibles and co-pays. The final cost is based on the plan chosen by your employer or individual insurance provider. To be covered under most plans, breast reduction surgery may require prior authorization from your insurance company before it can be approved and scheduled at a hospital or surgical center that participates with them.
what makes a breast reduction medically necessary
I recently saw a female college student as a new patient consultation in my office concerning possible breast reduction surgery. 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.
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.
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.
The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.
breast reduction requirements weight
From weight to health to mood, oversized breasts create unnecessary heaviness. If your breasts are weighing you down, a breast reduction surgery could lighten up nearly every aspect of your life. Let the experts at Aesthetic Surgical Arts/Mia Bella Donna Medspa in Overland Park, KS, show you the way toward greater freedom with a mammaplasty.
What Is a Breast Reduction?
If you are living with large breasts, you already know how painful they can be. Sometimes it may feel like you are carrying the weight of the entire world on your shoulders. You may wonder why many women long for large breasts when yours have caused you great discomfort.
A breast reduction, or mammaplasty, is an operation to decrease your cup size. Although changing the size and weight of the breast is the most common reason women reduce their breast size, this surgery can also address breast positioning and shape. This empowering procedure helps women achieve optimal health with enduring, lifelong benefits.
Who Could Benefit From a Breast Reduction?
Any woman unhappy with their large breasts could benefit from reducing the size. Many women with enlarged breasts experience health problems that impact their daily lives. Women of all ages are eligible for this procedure.
Although many women recognize that their very large breasts cause their symptoms, many others don’t because they seem unrelated. Some problematic symptoms of oversized breasts include:
Chronic Pain
Ongoing pain in the neck, back, and shoulders are a fact of life for many women with big breasts. The breasts themselves can feel too heavy to carry. Your pain may range from mild to severe, but chronic pain is always a reason to contact your doctor.
Breathing Difficulties
Breast weight can impair your ability to breathe normally, and you may not even realize it. The excessive poundage on the ribs and diaphragm can make it more difficult for you to breathe deeply. Some women notice the effects more when lying on their backs.
Poor Posture
The weight of breasts takes a toll on your posture. All the yoga in the world may not be enough to keep your spine straight. Big breasts can put too much pressure on your frame, resulting in a curved posture. Years of bearing the weight could eventually lead to a spinal deformity if the chest and back muscles aren’t equipped to handle the load.
Low Self-Esteem
Your breasts can influence the way you feel about yourself. Whether you are struggling with pain, tired of never finding clothes that fit or receiving unwanted attention, you could be a candidate for this procedure. Although women with large breasts are the typical candidate for this procedure, we can help any woman who wants to reduce her cup size.
Grooved Shoulders
Finding a supportive bra for larger breasts has become easier in recent years, but finding the right strap to weight ratio is still a challenge. Large breasts need wide bra straps, but even wide straps sometimes aren’t enough. If your straps don’t support the weight of your breasts fully, it can lead to deep and painful grooves in the shoulders. After a time, these grooves can even cause scarring on your shoulders.
Rash or Infection Under the Breast
Weight isn’t the only cause for concern with big breasts: also common are rashes under the breasts. Large breasts trap in heat, moisture, and bacteria that can lead to rashes or other infections. A skin infection or rash almost always leads to some form of irritation or pain.
Migraines and Tension Headaches
Your breasts may cause migraines or tension headaches. Evidence suggests that women with large breasts have a dramatic reduction in head-pounding headaches after reducing the size of their breasts.
Tingling and Numbness
If you have tingling or numbness in your arms, fingers, or hands, your overly large breasts could cause it. Excessively large breasts combined with poor posture can obstruct the pathways of nerves to create that uncomfortable numbing or tingling feeling.
Trouble Exercising
If you struggle to exercise due to the size of your breasts, you aren’t alone. Many women with bigger cups sizes have a tough time getting the recommended amount of physical activity in the day-to-day. A sports bra can only go so far in protecting your sensitive tissue, and a breast reduction may be your best bet.
Will Losing Weight Reduce My Breast Size?
Many women experience a change in breast size when they lose weight. Breast tissue is primarily fat, which you can lose through diet and physical activity. However, not every woman can expect a significant reduction in breast size from exercise; therefore, it’s an unreliable method for reducing this area of the body.
Reducing Your Breast Size Helps You Lose Weight
Staying active and eating a well-balanced diet is the best way to safeguard your health. If you can’t engage in physical activity comfortably, reducing your breast size could have a two-fold effect. It removes the discomfort caused by your breasts and makes working out possible.
Will I Lose Weight After a Breast Reduction?
Yes, you will probably lose some weight after this procedure because you are removing fat from your body. The amount of weight you’ll lose depends on how much tissue you remove with surgery. However, you shouldn’t expect your operation to tip the scales. Even the largest breasts only weigh only a few pounds per breast.
One of the most significant advantages of weight loss after breast reduction surgery. Most women report feeling much more capable of exercising and maintaining their weight after the operation. It’s common for women to lose between 10 and 20 pounds in the months following surgery. This weight loss is a combination of the ability to partake in physical activity, and the motivation resulting from a woman enjoying her new physique.
You’ll Look Like You Lost Weight
One disadvantage of having large breasts is how it skews your proportions. Many women who have disproportionately large breasts look like they weigh more than they do. A benefit of reducing breast size is that it seems like you’ve lost a lot of weight, even when you haven’t.
This effect is especially marked in women who have a smaller frame and a bigger bust. Many women report others commenting on how much slimmer and taller they look after reduction surgery. Even though you won’t lose substantial weight from removing breast tissue, you will probably look like you have.
Should I Lose Weight Before a Breast Reduction Procedure?
If you are not at your target weight, it’s a good idea to lose weight before your procedure. If you have your reduction before losing weight, it could impact the results of your surgery. Losing a lot of weight after a reduction operation could result in you having smaller breasts than you want. It may also cause changes to the skin changes and the overall shape of the breasts.
Your best bet is to achieve your desired weight and maintain it for a few months before scheduling your appointment to reduce your breast size.
Things to Know
Before undergoing this life-changing operation, it’s essential to know what to expect. Although no two women are exactly alike, there are several results women commonly share after reducing their breast size.
Our Premier Johnson County Facility
Skip the hospital: your procedure takes place in our state-of-the-art Johnson County facility. We carefully remove the unwanted fat, tissue, and skin from your breasts to reduce the size. We reshape them to your desired firmness and roundness all in the comfort of our pristine surgical facility and Medspa.
Loving the Results
This surgery has one of the highest patient satisfaction rates immediately and after ten years post-op. According to studies, 95% of women feel extremely satisfied with the results of removing breast tissue. The reason for these rave reviews is simple: this operation treats all the painful symptoms associated with bigger breasts.
Your quality of life is bound to improve when you remove chronic pain from your life. You can say goodbye to back, neck, and shoulder pain while breathing more deeply every day. Your entire world opens up with opportunities and possibilities that you may never have considered before.
An Outpatient Procedure
We usually perform this safe procedure on an outpatient basis under general anesthesia. In only a few hours, your surgeon transforms your bust to more manageable proportions, and you typically won’t have to stay in a hospital for days after the operation.
You Can’t Choose Your Cup Size
This aspect may sound concerning to you, but it makes sense when you put everything into perspective. Bra sizes vary from one company to another, and there isn’t a universal standard for cup sizes. Although you are probably accustomed to identifying your breast size with a letter, it’s more useful to think about how you want your breasts to look after surgery.
During your consultation, your surgeon will discuss your breast goals with you to understand what you want the result to be. Together you find a size that works for you and your body. Also, keep in mind that the results immediately after surgery may not be what you had in mind. It takes a little time for your breasts to settle into their new size and shape.
is it hard to get insurance to cover breast reduction
If you are reading this article, you are likely considering breast reduction. It has become more and more common to consider a breast reduction procedure. There are many reasons that women consider breast reduction which can include post-childbirth changes or that your breasts have become so large that they are hindering everyday activities such as exercising. A breast reduction procedure that can benefit you in many ways.
Many women wonder if your insurance benefits cover a breast reduction surgery. If you are asking yourself, “does insurance cover breast reduction?” you are not alone. Our office is asked this question frequently and we work hard to ensure that our patients know all of their options and exactly what their insurance company will provide and what they will not cover.
There are Many Reasons You May Be Considering Getting Your Breast Reduction Covered by Insurance
Unlike many places on our body, it is often very difficult to lose weight in the breasts. It has become a bit of a catch 22. For example, many women seeking to lose weight can perform all the cardio exercise that they can, while still not losing weight in their breasts. However, having extremely large breasts can also lead to pain when performing cardio exercise such as running, leading to a hindrance to do so, hence the catch 22.
If you are considering breast reduction surgery cost may be an issue when considering the procedure. However, what many women don’t know is that there are important factors that are considered when you are trying to get a breast reduction surgery through your insurance company. This is ideal for women who truly struggle with having breasts that are interfering with their everyday life and activities.
If you are considering having your breast reduction covered by insurance, here are a few different important points that can help make your case for a breast reduction covered by insurance.
See a Chiropractor or Physical Therapist for Neck and Back Pain
For many women, one of the reasons they are considering having breast reduction surgery in the first place is due to back pain, neck pain, shoulder pain, or just general stress on the back area. The first step is typically to visit a physical therapist or chiropractor in order to have your specific pain looked at. During your visit make sure you mention that you are considering a breast reduction surgery to alleviate your pain. Ask them to make a specific note on your patient file documenting your symptoms of pain and discomfort. These visits will show them that your symptoms are truly causing you pain and that you have made additional attempts to remedy them prior to going the route of surgery.
Meet with Your Primary Care Physician
When looking to get a breast reduction covered by insurance, it is important to meet with your primary care physician to discuss your symptoms from dense heavy breast tissue. A primary care physician will document the pain you are having and go over the long-term effects of neck and back pain. Don’t forget to include minor pains like being uncomfortable due to pain from bra straps digging in deeply. This will give you another example to show that you have a real physical problem and are not just seeking a cosmetic breast reduction surgery.
Meet with a Plastic Surgeon
Meet with a plastic surgeon, specifically one that specializes in breast reduction surgeries. A consultation will demonstrate that you are being proactive in gathering information to help make the best informed decision regarding a surgical procedure. A plastic surgeon will be able to write a letter of medical necessity which will highlight the important history of neck and back pain along with the treatments and recommendations of your other doctors. A plastic surgeon will include as part of that letter the number of grams to be removed from each breast that is an important parameter for the insurance company to review as part of the pre operative authorization process.
Insurance companies may require pre operative photographs as part of the pre authorization process for a breast reduction procedure. As part of the insurance pre authorization each insurance company will let the physicians office know if photographs are required.
Note Specific Activities That Are Affected by Your Breast Size and Pain Caused
These can also include physical symptoms, such as being uncomfortable sitting at work all day with your bra straps digging sharply into your shoulders. While these are not medical proof you need back pain, it gives insurance company a better idea of why you should have breast reduction surgery insurance covered.
A breast reduction surgery can have many great benefits and help you live a more confident, active lifestyle. A plastic surgeon who performs breast reduction surgery on a regular basis will work diligently with you to get your insurance company to cover the procedure. As long as your insurance company receives all of the medical necessity and pre operative information regarding your case they will likely approve the procedure. Most insurance companies just want to make sure your surgery is not being performed for cosmetic reasons.