Many women undergo breast interventions such as augmentation, reduction or reconstruction for various reasons. These procedures can be costly and some may wonder if their insurance covers these costs.

In this article, we will discuss insurance contracts and breast interventions and what is covered.

Types of Breast Interventions

There are various types of breast interventions performed by plastic surgeons. These include:.

Breast augmentation, which involves the use of implants to increase breast size
Breast reduction, which involves the removal of breast tissue to reduce breast size
Breast reconstruction, which involves the creation of a new breast after a mastectomy or other trauma

Insurance Contracts and Breast Interventions

Insurance companies typically have specific language in their contracts regarding breast interventions.

Some insurance companies may only cover these procedures if they are deemed medically necessary, such as in cases where breast reduction is needed for back pain relief. Other insurance companies may offer coverage for breast reconstruction after a mastectomy. However, coverage can vary greatly depending on the insurance company and the specific policy.

Prior Authorization

In some cases, insurance companies may require prior authorization for breast interventions. This means that the insurance company must approve the procedure before it can be performed.

This process can take several weeks and involves submitting documentation from the plastic surgeon regarding the medical necessity of the procedure. Failure to obtain prior authorization could result in the insurance company denying coverage for the procedure.

Covered Costs

If a breast intervention is covered by insurance, there may still be out-of-pocket costs for the patient. These costs can include deductibles, co-pays and co-insurance.

The patient may also be responsible for any costs associated with pathology or imaging tests performed prior to the procedure.

Reasons for Denial of Coverage

There are several reasons why insurance companies may deny coverage for breast interventions. These can include:.

The procedure is deemed cosmetic and not medically necessary
The patient has not met the criteria for prior authorization
The procedure is not considered standard of care

Appealing a Denial of Coverage

In some cases, patients may be able to appeal a denial of coverage for a breast intervention. This involves submitting documentation and medical records to the insurance company and explaining why the procedure is medically necessary.

Patients may also need to enlist the help of their plastic surgeon to provide additional information.

Other Options for Covering Costs

If a breast intervention is not covered by insurance, there are other options for covering the costs. Some plastic surgeons may offer financing options or payment plans to help patients pay for the procedure over time.

Patients may also consider medical credit cards, such as CareCredit, to cover the costs of the procedure.

Conclusion

Breast interventions can be life-changing procedures for many women. Understanding insurance contracts and what is covered can help patients make informed decisions about their healthcare.

If you are considering a breast intervention, be sure to consult with your plastic surgeon and insurance company to determine coverage and out-of-pocket costs.