How Do You Get Insurance to Pay for Breast Reduction?

Not all plastic surgeries are purely cosmetic. Breast reduction surgery is an example of a plastic surgery procedure that often brings significant relief and improves a patient’s health and quality of life, relieving them of chronic pain or other symptoms. This blog will discuss when breast reduction is covered by insurance and how to get started on the process of getting insurance coverage, offering hope and optimism to those considering this procedure.

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What Is Breast Reduction Surgery?

Also known as reduction mammoplasty, breast reduction is a plastic surgery procedure designed to remove excess tissue from the breasts and decrease their size. Like any surgical procedure, breast reduction surgery carries potential risks and complications, which your surgeon will discuss with you during the consultation.

There are several reasons for breast reduction surgery, including:

• Overdeveloped breasts: Very large breasts (macromastia) or excessively large breasts (gigantomastia) can cause both physical discomfort—such as shoulder pain or dermatitis— and emotional distress. These conditions often develop in puberty, but their cause is largely unknown.
• Enlarged male breasts: Gynecomastia, or overdeveloped male breasts, can cause psychosocial distress. This condition is often only correctable with surgery if it doesn’t go away on its own.
• Gender affirmation: Also called top surgery or chest masculinization, breast reduction is a common gender-affirming surgery.
• Asymmetrical or Post-mastectomy adjustment: If breasts are asymmetrical, or after breast cancer surgery (mastectomy or lumpectomy)  C, one or both breasts may benefit from a reduction to create symmetry.
• Cosmetic improvement: Sometimes, an individual just feels they’d look better with a reduced breast size. Cosmetic surgery provides an enhanced appearance and self-image.

Does Insurance Cover Breast Reduction?

For a health insurance company to cover a breast reduction procedure, it has to be deemed medically necessary. This means that the surgery will address chronic health issues. Symptoms of chronic issues caused by oversized breasts may include:

• Chronic pain in the back, neck, or shoulders
• Arthritis in the spine
• Skin irritation and grooves caused by bra straps digging into the flesh
• Skin problems such as inflammation, infection, rashes, bleeding, and excessive moisture

You will need to check with your health insurance provider to see what is considered a medical necessity for breast reduction surgery. You will most likely need to acquire prior authorization, sometimes called pre-authorization. The prior authorization process involves your surgeon communicating with your insurance company, providing health records, and other documentation to get approved for surgery. This process can take some time, so it’s important to start early. If you are not approved, the surgery will be considered cosmetic, and your insurance won’t cover it.

When Is a Breast Reduction Medically Necessary?

There are a few guidelines when it comes to determining the medical necessity of a breast reduction. First, you will need a surgeon (and possibly two or three other specialists) to back you up, and you’ll likely need them to write a letter or compile health records or some other form of documentation. Next, you may need to prove that you have already tried non-surgical treatments, like weight loss or physical therapy, which did not work. Finally, some health insurance plans require proof that you have had symptoms for at least six months.

Some conditions that may get approved for breast reduction surgery coverage include:

• Dermatitis, severe rashes, or skin infections that are difficult to treat
• Limited physical activity
• Nerve problems due to the weight of breasts
• Posture or spine problems due to breast weight
• Back, neck, or shoulder pain that is persistent
• Shoulder grooves from support garments and bra straps

Ultimately, you will need to check with your health insurance company for specific criteria regarding their process.

How to Get a Breast Reduction Covered By Insurance

For the most part, the process of getting insurance to cover your breast reduction surgery will require persistence and plenty of thorough documentation.

You will likely need:

• A letter from your doctor about your symptoms and their history
• Your medical records, including previous treatment
• Photos or detailed descriptions of your breasts

The point of providing your records is to argue the case that breast reduction surgery is a medical necessity and not cosmetically motivated. You will detail your chronic health symptoms and treatments that have failed to address them.

Reach out to your health insurance company to find out exactly what you need to acquire in order to prepare the prior authorization request. Then, assemble your team of specialists: talk to your primary care physician and consult with a board-certified plastic surgeon. A board-certified plastic surgeon is crucial in this process as they can provide expert advice, support your case, and provide letters or other necessary documentation.

Interested In Breast Reduction Surgery in High Point, NC?

We can guide you through the process and answer any questions you have. Dr. Willard is an experienced and compassionate board-certified plastic surgeon who has helped hundreds of patients achieve their desired results. To learn more about insurance and financing for breast reduction, schedule a consultation by calling (336) 886-1667 today. You are not alone in this journey, and we are here to support you every step of the way.