For many women, the goal of a breast reduction (reduction mammaplasty) surgery is to improve or eliminate some very real physical symptoms related to a large breast size. Appealing breast reduction results sometimes necessitate a breast lift (mastopexy) of the remaining breast tissue and nipple. Even though these facts may make it seem that your health insurance should, logically, cover part (or all) of your breast reduction and lift cost, there’s no guarantee.
Medical terms for large breasts include macromastia, gigantomastia, and breast hypertrophy. Although breast reconstruction after mastectomy is covered by most insurers, it can be difficult to get insurance coverage for a breast reduction and nearly impossible to get coverage for a lift. However, it is still worthwhile to check into this option.
The bright side here is that most patients who undergo a successful breast reduction and lift rate the procedure “worth it” after the fact, even when they foot the bill all on their own.
Here, we’ll share some information about our patient’s experience with breast reduction and insurance coverage, which may help reduce your costs as you go forward with your breast reduction and lift.
Is a Breast Lift Always Needed with a Reduction?
Most breast reductions will result in lifted breasts because your surgeon must reshape the remaining breast tissue after removing the “excess” tissue as discussed in your surgical consultation. Whether or not there is enough work involved to cause the breast lift procedure to be billed as a separate surgery depends upon your surgeon’s policies, your goals and the details of your surgical plan.
In general, nipples must be repositioned higher on your reshaped breasts (and/or the areolae made smaller) after a reduction. This requires significant skill and planning and is considered a separate breast lift—even though it is typically performed at the same time as your breast reduction. You and your NJ plastic surgeon should discuss this at your consultation. The best plastic surgeons want to ensure you have no surprises after your breast surgery. These surgeons want you to know what to expect and will use all their skills and spare no effort, to ensure you get the best result possible.
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Breast Reduction Insurance Coverage: No Guarantees but Worth Checking Into
As most of us have experienced over the years when dealing with our personal health insurance policies, each health insurance carrier seems to have a unique point of view on what constitutes “medical necessity.” Medical necessity seems to be the low bar for qualifying for coverage, however, even if your surgery is medically necessary (under your specific insurance company’s definition) they still may refuse coverage.
To muddy the waters further, insurance companies may change their rulings from plan year to plan year. Procedures (and medications) covered in a prior year are sometimes cut out of future coverage. So, getting approval in advance of any surgery (where you’re counting on help from your insurance company) is crucial.
As an example of the medically needed care that’s often not covered by insurance these days: you may need to wear glasses or contact lenses to function in daily life, which sure sounds medically necessary. Yet many insurers no longer offer any vision coverage unless it rises to the level of eye disease, like glaucoma or cataracts. Gum disease can lead to systemic illness throughout the body, yet many insurers no longer cover basic dental care. As another example, most insurers tend to refuse coverage for any procedure they deem “experimental” as well, even if your physician feels it is necessary.
How to Use Health Insurance for Your Breast Reduction and Lift
Here are some tips that are drawn from our experience with insurers, and information our patients have shared with us to help you get coverage and understand your coverage details clearly:
- Read your insurance coverage materials or see the company’s online resources for your particular level and type of health insurance coverage. See if you can determine whether they might cover breast reduction to alleviate symptoms you may have. Never trust your own interpretation of insurance company rules, however. Checking what’s in writing may help you learn something about the conditions under which your procedure might be covered or the process to request coverage.
- Then call your insurance company and see if pre-approval is required for breast reduction and lift surgery.
- Find out what documentation your company requires from your physician to establish medical necessity. Getting documentation of your symptoms from your family doctor and your plastic surgeon would likely be the most convincing.
- If your insurer believes that your large breasts are causing symptoms (shoulder pain, back pain, skin rashes or infection, etc.) that will require ongoing, expensive treatment (that they will have to pay for), they are more likely to approve coverage (or partial coverage) for your breast reduction. But also remember–there are no guarantees that your insurance company will respond to this logic.
- Find out if your insurance company requires a second medical or surgical opinion before approving coverage for your breast reduction and lift. Determine if they must choose the physician for your second opinion.
- Find out if your health insurance company requires you to use a plastic surgeon from within their network. Having a surgeon that you trust (with years of advanced surgical experience) performing your breast reduction is crucial to a successful outcome that you will love.
- If you have a network restriction that limits your choice of surgeons, you might want to find out if you can use the plastic surgeon of your choice–if you’re willing to rely upon less coverage from your insurer. Some companies allow out-of-network procedures at a reduced rate of coverage, while some companies disallow out-of-network care in non-emergency situations.
Health Insurance May Cover Breast Reduction
There are many cases where health insurance covers some or all of the costs of a breast reduction. With that said, health insurance typically does not cover cosmetic plastic surgery, except to restore the body to proper function after an injury, to repair certain function-impairing birth defects and for reconstruction of one or both breasts after a mastectomy. The important distinction is which reduction is cosmetic and which is medically necessary.
Some insurers may cover breast reduction surgery for those who have documented health problems that can be attributed to large or heavy breasts.
The size of the planned reduction will be taken into account as well as symptoms including back, neck or shoulder pain, spine problems, skin rashes or infections, and nerve damage. An insurance company may ask for verifying documentation such as photos, evaluation from orthopedic surgeon or dermatologist. Before obtaining these you should seek a consult with a plastic surgeon.
Health insurance companies tend to vary greatly in what they agree to cover, so you need to check carefully and not assume anything. As you may be aware, some insurance providers may cover a test, treatment or surgical procedure under one type of plan and not under another.
Insurance may or may not cover blood testing, mammography or the physical examination that must be done before your breast reduction. To further complicate matters, insurance plans may cover varying percentages of health costs that they approve, according to their own regulations and guidelines.
Many restrict your treatments to certain doctors and many require pre-authorization of your procedure. (The advantage to this is that you have a better picture of whether your breast reduction meets their requirements for coverage–and what your costs will be.)
Under health plans that assign you a primary care doctor to manage or coordinate your health care, like HMOs, you might have to ask your primary care provider for a referral to a specialist/plastic surgeon first.
The Breast Lift May be Excluded from Insurance Coverage
If your insurance company will entertain the idea of paying for your breast reduction, they may draw the line at a breast lift, even if it’s done at the same time as your reduction. Still, getting coverage for part of the procedure is better than no coverage.
- In this situation, ask your NJ plastic surgeon which parts of your costs are attributable to the breast lift so that you clearly understand the part of the bill that you will be responsible for. For instance, there may be a surgeon’s fee that is just for the breast lift and there may be a certain amount of surgery center time that is devoted to or allocated to, the breast lift.
- Check with your insurance company about whether they will cover part of the anesthesia and other costs that have to do with both the breast reduction and lift. Some patients have mentioned that their companies would not give them this detail until after the procedure was completed and the company received the billing.
- If your insurance company does not pay what you feel they have agreed to cover according to your insurance plan with them, you may check into grievance procedures, ask them to reprocess the bills or to reconsider their decisions on coverage. Most companies have a procedure for this and it may be worthwhile to explore.
- If your health insurance company offers partial coverage for your breast reduction, check with your NJ breast surgeon to see if you must pay up front, then wait to be reimbursed by your insurance. (Not all plastic surgeons accept insurance, but you may be able to send your paid bills to your insurance on your own, after the fact, to achieve partial reimbursement, if the insurance company allows this method.)
- Your insurer may cover some of your pre-surgery testing if it falls into line with their scheduling/frequency requirements. For instance, if your insurance covers an annual physical or blood tests, and you haven’t had yours yet within the coverage period, it may be covered.
- If you have an HSA, or Health Savings Account that goes along with some High Deductible Insurance plans, or an FSA (Flexible Spending Account) through your employer or your business, some of the costs not covered by health insurance may fall within the “medical necessity” guidelines for these plans. These savings accounts are funded from your pre-tax dollars (or deducted from taxes–consult your tax advisor), so it would be like getting a discount on the surgery. Check with your plan administrator.
How Do Health Insurers Decide What to Cover?
In general, insurance companies base their treatment coverage decisions upon whether the surgery is medically necessary or optional. If a surgery meets the specific company’s requirements as medically necessary for your health, they may pay for all or part of a treatment. Insurance companies will typically refuse to pay for any purely cosmetic surgery.
Plastic and Reconstructive Surgery’s recent research showed that insurance carrier’s breast reduction standards are not necessarily in line with medical science and professional opinions.
Getting an Answer from Your Insurance Company
Your plastic surgeon or their office staff should help you navigate the question of insurance coverage. You should always get a definitive answer before going forward with breast reduction surgery if you’re relying on your insurance company to pay for some of the cost. Some tips that breast reduction patients have shared with us in the past include:
- For your peace of mind, research your insurance company’s policies in advance and get their written pre-approval, or pre-authorization, if possible.
- Do not assume you’re covered because a friend or family member was covered for breast reduction surgery (even under the same insurance plan as you have.)
- Do not interpret the insurance company’s written rules, guidelines, and materials for yourself. You’re just crossing your fingers by assuming anything based on the general wording. It’s essential to have permission for your specific case. If you were to go forward without getting a pre-approval, you’d have to be prepared to get a denial of your claim and have a backup plan or budget in place.
First Find Out if You’re A Good Candidate for Surgery
During your consultation with a New Jersey plastic surgeon, you’ll discuss your medical history and you’ll also be asked why you’re seeking a breast reduction. Be completely honest with your physician.
They will need to determine if you are a good candidate for breast reduction surgery, both physically and emotionally, before any talk about the potential costs can begin. If you are a smoker or have chronic medical conditions, you may not be a good candidate. However, there is no single attribute that will disqualify you, so it is wise to visit with a surgeon for a no-charge consultation about the procedure to learn more about your specific case.
Discuss Your Breast Reduction with a Plastic Surgeon in NJ
The first step in the breast reduction process is to meet with a breast reduction surgeon in NJ to discuss the surgery. You will be able to learn about the surgery, if you’re a great fit and what the next steps are.
Our Aesthetic and Reconstructive Surgeons are dedicated to your health and well-being. We are available to answer your questions and determine if you’re a good candidate for surgery.
If you are working with a dedicated breast specialist and plastic surgeon in NJ, he or she will typically be happy to provide required information to your health insurance company, with your permission, that may help them determine coverage for your breast reduction and lift. Your insurer may also require information from your primary doctor. Schedule a consultation with one of our expert surgeons at Cohen Winters to learn more about your breast reduction options.