Insurance coverage for breast reduction.
Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.
1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.
2) Very big reductions (like from an F cup to a C cup) will usually be covered.
3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.
4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.
5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.
6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.
7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.
8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.
9) Don't give up. If the first request is denied, demand an appeal.
10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.
Breast Reduction Insuracnce Requirements
Each insurance company has different guidelines. Moreover, insurance requirements are different depending on state and insurance plan. The process to receive insurance reimbursement for the breast reduction procedure can be quite frustrating.
There are a series of questions that must be answered prior to beginning the insurance process.
1. Have you experienced persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:
Pain in upper back
Pain in neck
Pain in shoulders
Painful kyphosis documented by X-rays
Pain / discomfort / ulceration from bra straps cutting into shoulders;
2. Have you had a mammogram within the last year?
3. Have you tried any of the following therapies for 3 months or more?
Supportive devices (e.g., proper bra support, wide bra straps)
Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
Physical therapy / exercises / posturing maneuvers
4. Have you seen a physician for the symptoms you have experienced? When?
Your physician must also be able to document symptoms such as back and neck pain, headaches, also needs to ensure that the estimated reduction is consistent with the insurance company’s requirements for your BMI.
Breast Reduction Insurance Criteria
Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses
Breast reduction: insurance coverage for you
Breast reduction: insurance coverage for you
Large breasts (#macromastia)
or breast hypertrophy can occur in a variety of conditions (family trait, post
pregnancy, excessive adolescent growth). In general when the excessive breast
size causes functional problems, insurance will generally pay for the operation
if more than 400 – 500 grams are removed from each breast dependent on your
individual insurance company requirements. These problems may include neck
pain, back or shoulder pain, hygiene difficulty, and breast pain.
Breast reduction, or reduction mammaplasty patients are among the most satisfied of all plastic surgery patients. Large breasts (macromastia) can often decrease quality of life for a woman. With breast reduction, you can have smaller breasts that sit higher on your chest wall. You will also find relief in your neck and back with the decrease in weight and more ergonomic position of your breasts.
There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.
1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.
2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.
3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.
Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.
The ideal size depends on the size of your hips and waist. Your surgeon will be able to guide you in this decision.
The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!
Breast reduction by insurance or not
I can clearly understand that you want your reduction to be done under your insurance and you can certainly visit surgeons who can write letters to your insurance seeking preauthorization of coverage. But please also know that these are the only breasts you will ever have and many of the very best plastic surgeons no longer work with any insurance as the reimbursement for a breast reduction to the doctor can be as low as a few hundred dollars depending on the insurance. This doesn't even cover the doctor's cost of doing the surgery. So you might want to find the very best surgeon even if they don't take insurance and have them discuss this with you. Look at lots of photos and go to the best doctor regardless of insurance.
Insurance Coverage & Breast Reduction Surgery
surgery is often covered by insurance carriers, but breast lift is never
covered by these companies. Some insurance companies actually exclude breast
reduction as a contract exclusion. When insurance carriers cover breast
reduction, they may have specific criteria that must be met. For instance, most
insurance carriers require documentation of symptoms. Examples would include
back pain, shoulder pain, breast pain and headaches to name a few. They may
also require documentation of attempted non surgical management of symptoms.
Examples might include physical therapy, support devices and anti-inflammatory
drugs. Some insurance carriers require a minimal amount of breast tissue removal
from each breast. This is often based on calculations, which utilize the
patient’s weight and height.
The process starts
with a consultation. At that time, pictures are taken and a prior authorization
letter is sent for approval. It typically takes about six weeks to obtain a
response. If your insurance carrier’s criteria are met, you are ready to
schedule surgery. Blue cross blue shields criteria varies from state to state,
but in most states, it has a high approval rate.
Breast reduction and lift
You will likely benefit greatly from a lift and reduction. The insurance portion only applies to the reduction, but usually a lift is an important part of the procedure to obtain the best looking results.
Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.
Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage. Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed. If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay. Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee. There is a geographic difference as well. It will vary from $8000-$10,000. Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits. Good luck to you.