Breast reduction procedures where a large amount of breast tissue is removed from each breast are occasionally covered in part or entirely by insurance.
Breast lifts are cosmetic operations and not covered by insurance.
Many patients ask whether insurance covers breast reduction or breast lift. The important criteria to note in patients requesting breast surgery are as follows:
Insurance coverage for breast surgery has specific indications and rightly so. Insurance companies cannot cover all patients requesting cosmetic enhancement of their breast. Rather, they insure patients who have physical symptoms related to the heaviness of the breasts.
A reduction is similar to a breast lift but has the added benefit of a decreasing the volume of the breast. A plastic surgeon should be familiar with this difference.
Breast Lift (Mastopexy) and Breast Reduction are described by two separate procedure codes ("CPT codes") when a bill is submitted to the insurance carrier. Health insurance carriers routinely deny payment of the CPT code for Breast Lift (Mastopexy). This procedure is considered cosmetic, and therefore not medically-necessary, by insurance carriers.
Occasionally, there are exceptions to the rule, however. If patients have had massive weight loss following bariatric surgery, they may suffer from intractable rashes and skin irritation from the loose, sagging breasts. Although technically these cases usually involve more lifting of the breast than reduction (since the goal in these cases is to preserve most of the native breast tissue), some insurance carriers can be persuaded that the procedure is medically-necessary because the rashes and skin irritation cannot be successfully managed other than by lifting the breasts and removing the excess skin. In this circumstance, the CPT code for Mastopexy will be used.
Breast Reduction surgery also involves a component of breast lifting. If the breast reduction meets the criteria for medical necessity in terms of the weight of breast tissue removed, the lift will be covered, although not directly. In this case, the CPT code used to describe the procedure will be the Breast Reduction code.
In general, a breast lift is considered a cosmetic operation and therefore is not covered by insurance. A breast reduction, if the breasts are reduced at least two cup sizes, is usually covered by insurance (each insurance company has their own criteria and evaluate each case individually).
However a question I often get - is whether a lift can be done at the same time as a reduction. The good news is that a reduction does both - reduces and lifts the breasts. Therefore, this is a circumstance where a lift can be covered by insurance!
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