Breast Reduction and Lift Insurance Coverage Requirements?

 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
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.