Breast reduction surgery, also known as reduction mammoplasty, is a cosmetic surgery that is performed to remove excess fat, skin, and glandular tissue from the breasts.

Large breasts can cause several health issues, including back and neck pain, skin irritation, and difficulty in breathing. Breast reduction surgery can help alleviate these issues and improve the patient’s quality of life. However, the procedure is not cheap, and most patients wonder whether their health insurance will cover it.

Criteria for Insurance Coverage of Breast Reduction

The criteria for insurance coverage for breast reduction surgery can vary depending on the individual’s health insurance company and the state in which they live.

However, some general guidelines can help determine whether your insurance will cover it:.

1. Medical Necessity

In most cases, insurance providers will only cover breast reduction surgery if it is considered medically necessary.

Breast reduction may be considered medically necessary if the person suffers from persistent back, neck, or shoulder pain due to the weight of their breasts. Other conditions that may be considered medically necessary include skin irritation, rashes, and infections under the breasts.

2. Documentation of Symptoms

To qualify for insurance coverage, the patient must provide documentation of their symptoms. This includes medical records, photographs, and a doctor’s note stating that the patient’s breast size is causing medical problems.

The records should show that the patient has attempted alternative treatments such as physical therapy or pain medications without success.

3. BMI requirements

Some insurance companies may require that the patient’s body mass index (BMI) is within a specific range before considering coverage for breast reduction surgery. They may also require the patient to lose weight before the procedure.

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This is because obesity can increase the risks of complications during surgery.

4. Age requirements

Most insurance providers will not cover breast reduction surgery for minors unless there is a medical necessity. In most cases, insurance companies require patients to be at least 18 years of age to qualify for coverage.

5. Prior Authorization

Before undergoing breast reduction surgery, insurance companies may require prior authorization from the physician. This involves submitting documentation of the patient’s symptoms and medical history.

The insurance company will then review the information and decide whether to approve or deny coverage.

Out-of-Pocket Cost for Breast Reduction Surgery

If the patient does not meet the insurance company’s criteria for coverage or if their insurance policy does not cover breast reduction surgery, they will have to pay for the procedure out of pocket.

The cost of breast reduction surgery can vary depending on several factors, such as the surgeon’s fees, anesthesia fees, facility fees, and post-operative care. On average, breast reduction surgery can cost anywhere from $5,000 to $10,000.

Final Thoughts

In conclusion, breast reduction surgery can be a life-changing procedure for individuals with oversized breasts. However, insurance coverage for the procedure can be challenging.

It is essential to understand the criteria for insurance coverage and work with your healthcare provider to provide the necessary documentation to the insurance company. Patients who do not qualify for insurance coverage may have to consider financing options or paying for the procedure out of pocket.