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.