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Is breast reduction covered by health insurance?


I recently saw a female college student as a new patient consultation in my office concerning possible breast reduction surgery. This procedure, also known as reduction mammaplasty, is indicated for the treatment of symptomatic macromastia (large breasts). The commonly reported symptoms related to macromastia are neck, shoulder and back pain caused by the weight of overly large breasts upon the musculoskeletal system. Other secondary symptoms can include breast pain and dermatitis or rashes beneath the breasts.

The college student was referred to me by her gynecologist and arrived with a prescription recommending a consultation with a plastic surgeon due to her condition. The patient was under the common impression that because she was referred to me by another physician, that the suggested surgery would automatically be covered by her health insurance plan. She came in hoping that the breast reduction surgery could be scheduled in four weeks, during her winter break from college.

After completing a patient history and regional breast examination, my staff discussed with her what would be needed to obtain insurance authorization for her surgery.

As it turned out, this patient had no other medical treatment or previous consultations concerning her macromastia. She also had no history of being referred for physical therapy, chiropractic treatment, an orthopedic consultation or a dermatology exam. For many procedures, this lack of treatment history might not be an issue. But for breast reduction, which can be considered cosmetic or reconstructive, depending on the patient – and the insurance company reviewer – the lack of history for this patient would prove problematic.

Unfortunately, the patient had not completed all of the regimens that her insurance required for the reduction procedure to be covered in her case. She will be able to reapply for reduction mammoplasty coverage after the requirements have been completed, but, unfortunately, there is still no guarantee that her insurance will cover the procedure. Naturally, as a college student, she was not in the position to consider paying out-of-pocket for the procedure and was not happy to discover the insurance hurdles she would need to go through for potential coverage.

This story is just an example of why it's so important for patients to do their homework regarding their insurance coverage for any surgical procedure before seeing a surgeon. The answer to "is breast reduction surgery covered by health insurance?" can be very complicated and involve many variables.

Breast reduction and health insurance

It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure.

In the case of breast reduction, however, for insurance purposes, it will typically be considered a cosmetic procedure until the patient can prove an adequate number of health issues and attempted remediations of those issues prior to undergoing corrective surgery. Once the threshold has been reached, the insurance company may then consider breast reduction a reconstructive procedure for that patient and cover it. The problem is that the threshold can be different for every insurance company or insurance company reviewer. It is my opinion that breast reduction surgery has long been thought of as a "hybrid" procedure. It is considered reconstructive in attempts to obtain insurance coverage for the surgery, but it is also considered cosmetic in that patients expect meticulous aesthetic expertise in their surgery and results.

In our practice, it has become increasingly difficult to obtain insurance coverage for breast reduction surgery. Insurance companies frequently require 2-3 documented reports from other referred specialists before they'll consider covering it. Also, the insurance companies commonly request 6-12 months of documentation and treatment by either a physical therapist, chiropractor, dermatologist or orthopedist.

What does this mean for a patient who needs the procedure due to chronic health problems caused by macromastia? Keep yourself updated on policies during this process, as the insurance company's criteria are this year might not be the same next year.

If you feel that you are a candidate for breast reduction surgery and are requesting coverage under your health insurance, it is important that you contact your health insurance carrier and have them forward to you in writing their criteria for coverage. Every insurance company has different, independent criteria and indications. While your neighbor down the street may qualify for the procedure via one insurance carrier with a seemingly less severe situation, you may not be given the same answer by yours. On average, it takes between 3-6 months of preparation, including secondary consultations with other healthcare providers and possible therapy (physical therapy or chiropractics) to qualify for insurance coverage for breast reduction.

How do you handle this? Notify your primary care physician as soon as possible concerning any symptoms which may be related to your macromastia. It is never too early to start the process. Please contact your plastic surgeon's office with any questions you might have that relate to breast reduction surgery and coverage through your health insurance and they can try to help guide you through the process, so that you can obtain the care you need.

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