One of the most common questions asked during a breast reduction consultation is: Will my breast reduction surgery be covered by health insurance? The answer depends on the policy you have, but the surgery is generally considered a cosmetic procedure by insurance companies unless the patient can show an adequate number of related health issues. Some of the of the factors they consider include:
- Painful shoulder strap indentations and shoulder grooving
- Chronic back pain
- Pain between the shoulder blades
- Neck pain
- Headaches extending from the back of the neck to the forehead region
- Inability to work or exercise due to large breasts
- Rashes or chronic infections beneath or between the breasts
- Chronic breast pain due to large breast size
The threshold for coverage is different for every insurance company reviewer. Some insurance companies view breast reduction surgery as a cosmetic procedure and exclude breast reduction surgery from their policies, while other companies only require the doctor to deem the surgery “medically necessary.” However, most require a letter from the plastic surgeon documenting the above symptoms. The insurance company may have criteria suggesting that a certain amount of breast tissue be removed, taking into account the patient’s height and weight (body mass index or BMI). They may also look for documents indicating that conservative measures have been unsuccessful in treating large breast related issues. These documents may include treatment by a referring physician (primary care physician, gynecologist or back surgeon), physical therapist, chiropractor, and/or massage therapist.
After your initial consultation, a letter is typically submitted to the insurance company within 48 hours. Most insurance companies take 3-4 weeks to reply to the request. Keep yourself updated on policies during this process, as an insurance company’s criteria might change over time. Candidates for breast reduction surgery who are interested in requesting health insurance coverage should contact their health insurance carrier and have them forward their criteria for coverage.
Breast reduction surgery typically has a very positive and transformative impact on patients’ lives and is very gratifying to me as a plastic surgeon.