If you’ve been considering breast reduction surgery, chances are you have questions about cost. One of the most common questions we receive in this regard pertains to insurance coverage. Namely — “Is breast reduction covered by insurance?”

Of course, patients also have lots of other questions. 

They want to know how they will look after surgery … what recovery is like … when they’ll see their results … and many other things.

So, with this in mind, really the very best way to answer any of these questions is to schedule a one-on-one consultation appointment with Dr. Raja Mohan. Every patient’s situation is unique.

With that said, we will attempt to answer your most pressing questions regarding breast reduction surgery and insurance here. If you have additional questions, feel free to check out our other blog posts, or simply call our office to book an appointment with Dr. Mohan. 

Is Breast Reduction Covered by Insurance?

Have you found yourself Googling “breast reduction covered by insurance near me”?

You’re not alone.

A vast number of women out there are toiling with the struggles of heavy, cumbersome breasts. They know they need surgery to solve their symptoms, but they don’t have the money to pay for it out-of-pocket.

Unfortunately, many false beliefs have cropped up regarding this situation.

First, frequently patients believe that no cosmetic surgery will ever be covered by insurance. Therefore, they don’t even attempt to look into applying for coverage even when they desperately need a surgery like breast reduction.

On the other side of the coin, many patients believe that if a surgery is medically necessary — that is, if their breasts are causing back pain, headaches, etc. — then health insurance has to cover it.

In fact, both of these notions are false. 

Indeed, some cosmetic surgeries are medically necessary, and insurance will pay for them. In addition, not all procedures that a patient may deem medically necessary are seen as medically necessary to an insurance company. Moreover, even if an insurance company would be willing to pay for a surgery that a patient was in dire need of, the patient may have to jump through numerous hurdles in order to convince their insurance company that they need the procedure.

What Makes a Breast Reduction Medically Necessary?

This is a tough question to answer in just a few paragraphs. That’s because all insurance companies have different policies, and every patient will have a different situation and varied symptoms that may influence their need for surgery.

But if you truly want to know how to get insurance to cover breast reduction Blue Cross Blue Shield has a policy statement we can examine.

According to this document, patients must meet specific requirements. For example, patients must have:

• Fully grown breasts
• Documentation of neck, shoulder, and/or back pain
• Shoulder grooving
• Documentation of trying various other treatments such as inflammation-reducers, support bras, and heat-cold treatments

Will Insurance Cover Breast Reduction if You Are Overweight?

The breast reduction requirements weight barrier is usually the toughest hurdle for patients. Many insurers will not pay for breast reduction surgery if patients are over a certain weight as it is recognized that overall fat loss can often adequately reduce the size of the breasts. Note that BMI is generally used in place of weight alone. To know if your insurance company will cover this procedure at your current weight, contact your provider.

Does Insurance Cover Breast Reduction for Back Pain?

Not always. If your main concern is back pain, you usually must prove that you have had this problem for an extended period of time and that it is directly related to the size of your breasts. Most insurance companies want recorded documentation of prior doctors appointments or other tests patients have had concerning back pain.

Insurance companies also want to know that patients have tried other solutions to fix their back pain — for example, losing weight. An insurance company might require that anyone covered for this procedure have a BMI of under 30, which would require weight loss for some individuals.

FAQ: Breast Reduction Surgery Costs & Insurance

How much is a breast reduction with insurance?

This depends on the baseline cost of the surgery and the amount that your insurance company has agreed to cover. Some insurers will cover the entire cost of surgery if it has been deemed medically necessary while others will only cover a percentage of the total cost.

Does a breast reduction include a lift for the same price?

Basically, yes. In order to create new and natural looking shapes for your breasts after reduction, your surgeon will essentially be carrying out a breast lift, which means raising the position of the areolae and nipples and tightening any loose skin.

How can I convince my insurance to cover a breast reduction?

All health insurance companies have different requirements surrounding breast reduction surgery. Most insurers want to know that your symptoms (be they headaches, back pain, shoulder pain, labored breathing, rashes, etc.) are directly related to your breast size. Likewise, they want to ensure that you’ve tried everything else possible to fix the problem on your own. Only then might they consider covering this procedure.

Learn More About Paying for Breast Reduction Surgery

We certainly understand that not everyone can afford to pay for this critical procedure out of pocket. If you have questions about breast reduction surgery costs or insurance, please give our office a call today. Dr. Mohan would be happy to meet with you to discuss your candidacy for surgery as well as payment options and other important topics.

References

https://www.plasticsurgery.org/news/blog/is-breast-reduction-covered-by-health-insurance