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.
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.
Breast reduction and medicaid
Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier. Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front. Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days. The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.
Breast Reduction - Insurance Coverage
Probably, but you cannot assume that and, regardless, there are still some issues.
Each insurance company is different, and each has its own rules with respect to "coverage." It used to be that a 500 gram reduction (from each side) would be enough to qualify for insurance coverage, but that is no longer the case and cannot, in any event, be assumed to be the case. You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary." That may or may not be easy to do. If you start with the surgeons who participate in the insurance company you'll be off to a good start. If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.
Then, you'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.
The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.
I hope that this helps and good luck,
Breast reduction insurance coverage
The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're saying a well-trained/experienced board-certified plastic surgeon. Good luck!
Insurance coverge for breast reduction
Every insurance company is a bit different with regards to coverage for a breast reduction. You should contact your insurance company to find out their criteria.
Medicaid "COVERAGE" of Breast Reduction
We need to clarify some terminology.
Medicaid is notoriously difficult in approving / IE COVERING Breast Reduction surgery. So a lot of time would need to be spent writing them and documenting your situation. But - worse yet even if they "cover" (IE approve the surgery and agree to pay for it), the amount they pay the surgeons for this surgery is often preposterously too low. As a result, many surgeons prefer not to see Medicaid patients who approval process is frustrating and time consuming and whose reimbursement often does not cover the surgeons office expenses.
You may want to hear what some of our Illinois Plastic surgeons, especially Dr. Placik have to say specifically about your state's Medicaid program.
Dr. P. Aldea