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Does Insurance Cover Breast Reduction?

Health insurance rarely covers cosmetic procedures, but what about when something seemingly cosmetic is actually medically necessary? Here’s how you can get your insurance to cover breast reduction surgery.

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Knowing if insurance covers breast reduction surgery is important for anyone considering the procedure, as it can have a significant financial and emotional impact. Understanding your coverage can help you plan financially for associated costs, as well as give you better insight into which procedures or treatment plans might be the best suited for your needs. Additionally, some insurance policies may require pre-authorization before any medical procedures can be performed. By being aware of what your policy entails, you can work with your healthcare provider to figure out the best course of action that has the most coverage and lowest out-of-pocket cost.

Altering your body in any way is a difficult and personal decision that Americans face each day, and breast reduction surgery is no exception. For many, reducing the size of their breasts is more than cosmetic, it’s a procedure that may be medically necessary. Which begs the question, is it covered by your health insurance? Let’s get down to the nitty-gritty

What Is Breast Reduction Surgery?

Also known as reduction mammaplasty, breast reduction surgery is a procedure that can be performed only via surgery, and only from a board-certified plastic surgeon. The procedure is meant for those who are seeking to reduce their breast size due to a number of reasons - It can be used to address physical issues that may result from large or overly full breasts, such as back or shoulder pain, shoulder grooving, skin irritation, and bra-strap indentations. The procedure is often recommended for women who have overly large breasts relative to their frame and cannot find clothing that fits comfortably. Breast reduction surgery can provide both physical and psychological relief from the effects of having large breasts.

When It’s Medically Necessary

Breast reduction surgery isn’t always medically necessary. For example, there are those who choose to change their look for the sole purpose of self-esteem. While self-esteem and mental wellness are both important to the overall health of an individual, it isn’t always enough to convince insurers to pick up the tab for reduction mammaplasty.

Typically, health insurance companies will only cover the cost of breast reduction surgery if an individual’s enlarged breasts are causing health issues. Below are some of the most common reasons for medically necessary breast reduction procedures:

This can include those who have such large breasts that it causes them breathing issues, especially when they sleep. There are those who have such large breasts that sleeping on their back causes them restricted air movement due to the weight of their breasts pressing down upon their chest and putting pressure on their lungs.

Another, very similar and just as serious reason, would be for those who have too large of breasts for their natural frame and bone structure to hold up. If you are not proportionally built to have such large breasts, it can cause back, bone, and joint issues. Especially on the spine and neck, which can cause major problems that may require surgery down the road.

Safety Concerns & Side Effects

Possible safety concerns of having such a procedure done and the side effects that may follow the surgery are depending on a number of factors. Some of the main possible side effects of having the surgery include the possibility of decreased sensitivity in the breasts, particularly the area of the nipples. The surgery may also potentially alter the individual’s ability to breastfeed in the future, which can be a downside for those who are planning to be pregnant in the future and wish to breastfeed.

The main risk or safety concern for this procedure would be the possibility of an adverse reaction to the anesthesia and the potential for permanent scarring at the incision sites should poor healing occur.

Does Insurance Cover Breast Reduction?

Insurance companies may cover breast reduction surgery depending on their individual policies. Before considering the surgery, it is important to familiarize yourself with your insurance company’s coverage guidelines and any pre-authorization requirements they may have. In some cases, you may also need to be referred by a primary care physician before your insurance agrees to cover the procedure. Additionally, you will likely need to provide evidence of medical necessity for coverage of the surgery. By understanding the specifics of your health plan and any related requirements, you can work with your doctor to determine the best approach for getting a breast reduction covered by insurance.

Recovery Coverage

As far as how much of a patient’s recovery an insurance provider will cover for a breast reduction procedure, that will also differ depending on their policies and the breast reduction requirements for coverage. Some insurance plans will cover the full cost of recovery after surgery, while others will cover only a certain amount of time spent in a hospital and for medication to help recover once the patient leaves the hospital.

For example, depending on your situation, Aetna may assign a caregiver to aid you in your recovery process once you are home from the hospital. While many major carriers will offer some sort of benefits during your recovery, it’s important to check with your insurance company first, or find a plan that offers the coverage.

If you want to know more about insurance coverage for breast surgery, call 858-295-3438 to speak with a licensed agent or enter your ZIP code to compare quotes!

How to Get a Breast Reduction Covered by Insurance?

Insurance companies may cover breast reduction surgery depending on their individual policies. Before considering the surgery, it is important to familiarize yourself with your insurance company’s coverage guidelines and any pre-authorization requirements they may have. In some cases, you may also need to be referred by a primary care physician before your insurance agrees to cover the procedure. Additionally, you will likely need to provide evidence of medical necessity for coverage of the surgery. By understanding the specifics of your health plan and any related requirements, you can work with your doctor to determine the best approach for getting a breast reduction covered by insurance.

Who is Eligible for Insurance Coverage?

To be eligible for insurance coverage of a breast reduction procedure, individuals must first meet certain criteria. Generally, most insurers require that the patient has experienced physical or psychological problems due to large breasts and have tried other non-surgical treatments that have not been successful. The surgeon may also need to supply additional documentation such as medical records or images demonstrating the necessity of the surgery. Additionally, there are often age restrictions in place with regards to insurance coverage. Be sure to check your provider’s policy or contact your insurer directly if you have questions about what is covered and what isn’t.

Breast Reduction Surgery Cost

How much breast reduction surgery will cost you will differ, not only on your health insurance provider but also on what doctor you go to and in what state of the US you are in. The averages will be much higher in more largely populated cities versus if you were to seek a procedure from a doctor located in a more rural state.

Prices will be different, but according to FAIR Health, the total cost could be as high as 38,200 without insurance. Again, that price may be different based on your coverage level and out-of-pocket maximum.

How Much is a Breast Reduction With Insurance?

Breast reduction surgery cost with insurance can vary depending on the type and extent of the surgery, as well as the individual’s insurance plan. Generally, health insurance covers some or all of the costs associated with the procedure if it is deemed medically necessary. You will likely need to pay for any deductible, coinsurance, and copayments that apply to your policy. To get an estimate for the amount you’ll owe after insurance coverage, talk to your healthcare provider and contact your insurer to understand their individual policies.

According to estimates from FAIR Health, the total cost for a breast reduction surgery would be 16,036 at a hospital including Surgeon’s, Anesthesia fee and facility cost, etc.

Find Breast Reduction Surgery Coverage With FirstQuote Health

If you’re unhappy with your coverage or feel that it doesn’t do enough to cover your breast reduction procedure, then FirstQuote Health can help. With a uniquely accurate quoting engine that we’ve developed, FirstQuote Health has helped countless people just like you find and compare health insurance quotes in their area. Getting started is as easy as entering your zip code and answering a handful of questions.

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