Very huge breasts, often known as macromastia, might have negative health effects. Back, shoulder, and neck pain could result from the weight of the breasts. Some women develop persistent sores under the breasts or permanent shoulder grooves from bra straps.
Breast reduction surgery, also known as reduction mammoplasty, has psychological advantages in addition to treating physical issues like these. It can raise people’s quality of life, sense of self, and perceptions of their bodies.
If you’re thinking about having your breasts reduced, you probably want to know how much surgery will cost and whether your insurance would cover it. Cosmetic breast reduction surgery is not covered under insurance.
However, if you need the procedure for a medical condition, your health insurance may pay for it. The requirements for obtaining coverage for a breast reduction vary depending on your insurer.
Continue reading for more information on breast reduction surgery costs and when insurance will cover them.
Breast reduction and health insurance
Patients generally feel that if a procedure is deemed reconstructive, it is medically necessary and will be paid for by insurance. Contrarily, a lot of people think that if an operation is deemed cosmetic, it is not one that is medically necessary and covered by insurance.
However, until the patient can demonstrate a sufficient number of health difficulties and attempts to address those issues prior to corrective surgery, breast reduction will often be treated as a cosmetic procedure for insurance purposes.
Once the cutoff point is reached, the insurance provider might then classify breast reduction for that patient as a reconstructive treatment and pay for it. The issue is that every insurance company or insurance company reviewer may have a different threshold. Breast reduction surgery, in my opinion, has long been regarded as a “hybrid” operation.
It is seen as cosmetic in that people anticipate rigorous aesthetic competence in their surgery and results, but it is regarded as reconstructive in attempts to secure insurance reimbursement for the procedure.
In our clinic, it is getting more and harder to get insurance to pay for breast reduction surgery. Before they will consider covering it, insurance companies usually demand two to three recorded reports from other referred specialists. Additionally, insurance companies frequently want verification of 6–12 months of physical therapy, chiropractic, dermatologic, or orthopedist care.
What does this entail for a patient who needs the operation because macromastia is causing them to have ongoing medical issues? Throughout this procedure, stay informed about policies because the insurance company’s requirements this year might not be the same the following year.
It is crucial that you get in touch with your health insurance provider and obtain a written explanation of their coverage requirements if you believe you qualify for breast reduction surgery and want your health insurance to pay for it. There are unique, independent standards and indicators used by each insurance firm. While the neighbor down the street who appears to be in a less serious position may be approved for the procedure by one insurance company, you might not receive the same response from yours.
To qualify for insurance coverage for breast reduction, it often takes 3-6 months of preparation, including additional consultations with various healthcare professionals and potential therapy (physical therapy or chiropractics).
Does health insurance cover breast reduction?
It varies. Breast reduction is only covered by health insurance if it is deemed medically required to treat persistent health issues.
This implies that you’ll likely need to obtain insurance authorization before scheduling the breast reduction surgery.
The insurance provider will ask your surgeon to submit certain medical information on your behalf, after which it will determine if you actually need the procedure. (You’ll still have to pay copays or deductibles even if your insurance does cover the surgery.)
The insurance provider won’t pay for breast reduction surgery if it doesn’t match the medical necessity requirements of your health plan because it will be viewed as cosmetic.
How to get a breast reduction covered by insurance
The procedure of getting approval for breast reduction surgery can be protracted and difficult. Insurance companies use various standards to determine whether a procedure is medically required.
Your health insurance policy might demand that:
- a note from your doctor describing your symptoms and how long you’ve had them
- records from your past medical treatments
- Your stature and weight
- images of your bust
Generally, you must present documentation proving that:
- Your huge breasts are the cause of your ongoing health issues.
- You’ve attempted further nonsurgical therapies
- The nonsurgical therapies have not been effective.
Before providing coverage, several insurers demanded that a person is within 20% of their optimal body weight because weight loss on its own can result in smaller breasts. However, given that long-term weight loss is challenging and occasionally unachievable, some surgeons and scholars have questioned this criterion.
Your best course of action is to get in touch with your insurance as soon as you can and ask them to clarify all the requirements as well as the types of proof they would accept. You will then be aware of the precise documentation you need to compile and submit.
What qualifies as a medical need for breast reduction?
Surgery must be deemed medically essential by a doctor. You might have to show the doctor and insurance proof that you’ve attempted unsuccessful nonsurgical therapies like physical therapy, weight loss, or musculoskeletal treatments in the past. The insurance provider might want evidence that you’ve experienced symptoms for at least six months.
Medical necessity for breast reduction surgery may be accepted by insurance carriers if:
- You have difficult-to-treat skin infections or severe rashes.
- Your range of motion is constrained.
- Your nerves are compressed as a result of the weight of your breasts.
- Your posture and spine alignment are greatly being impacted by the weight of your breasts.
- You feel soreness in your breasts.
- You feel pain in your shoulders, neck, or upper back.
- Bra straps left grooves on your shoulders.
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