Insurance coverage for breast lift or breast reduction.
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 Asymmetry, Pain, and Insurance
From your symptoms and breast asymmetry you probably have a good likelihood that you will be covered by your insurance. 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.
Breast asymmetry and insurance coverage
Thank you for your question. Breast asymmetry is very common, particularly size asymmetry. If you are looking to decrease the asymmetry from one breast to another, then you have several options:
1) You can reduce the larger breast with liposuction or a traditional breast reduction technique
2) You can enlarge the smaller one with fat grafting or an implant
3) You can enlarge both but use different size implants
4) A lift procedure may also be needed to help address differences in shape, nipple position and areolar size.
Insurance coverage for asymmetry coverage may be challenging as insurance companies don't usually cover implants unless it is for cancer reconstruction. They may cover breast reduction of the larger size if there are specific medical concerns like back pain, neck pain, etc... They will require extensive documentation and it may still not be covered.
I would visit with a board certified plastic surgeon to discuss your options in more detail.
Breast reduction covered by insurance
Depending on your situation, insurance may be able to subsidize the cost of breast reduction. Some breast reduction coverage requirements where I practice in Ontario include your current cup size, the amount of breast tissue removed during surgery, unsuccessful experiences with alternative treatments and medications, as well as recommendations for breast reduction from other specialists, such as chiropractors and neurosurgeons.
Please contact your insurance provider to find out if your procedure will be covered.
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.
Medicaid Coverage for Breast Reduction of a C and DD Cup Breasts
The requirements for bilateral breast reduction coverage by Medicaid have always been so rigid as to make it almost impossible to have them agree to cover the procedure. If you could get it approved it will be hard to find a plastic surgeon to accept the fee that Medicaid pays for this procedure.
Breast Reduction and Medicaid?
Thank you for the question.
Medicaid has been known to cover breast reduction surgery. For multiple reasons, most plastic surgeons that I know of to not work with Medicaid. I think finding a reputable plastic surgeon who will work with Medicaid will be the challenge you will face.
Each insurance carrier has different criteria for pre-approval of a breast reduction. You should check with your insurance carrier.
Medicaid Breast Reduction
Medicaid will likely cover the procedure. Your problem may be finding a surgeon who will be willing to accept this as payment in full. It is quite difficult for surgeons to cover the costs of running their practice when reimbursed at these low rates.