Will insurance pay for my breast reduction surgery? In general, the answer depends on several factors. Is this breast reduction surgery considered a cosmetic procedure, or is it ‘medical’ in nature? Who is having the surgery and what are their reasons? If you are thinking about a breast reduction operation, you’re likely wondering how to get your breast reduction covered by insurance. There is a specific process you can go through, which involves both a surgeon and your insurer. We’ll take you through the steps of getting insurance coverage for breast reduction surgery.
- Exclusion: something your medical insurance refuses to cover
- Reduction mammoplasty: medical term for a breast reduction operation
- Macromastia: medical term for abnormal enlargement of the breasts
- Schnur scale: a method for comparing body surface area and amount of breast tissue to be removed. Sometimes used by insurance companies in determining coverage.
So, how do you get your breast reduction covered by insurance?
Steps to getting insurance coverage for breast reduction surgery
1. Check if your insurance has an exclusion for reduction mammoplasty.
If your insurance lists reduction mammoplasty as an exclusion, this means your insurance will not cover the procedure. Most insurance companies will NOT have this listed as an exclusion. If it is not listed, there is potential for getting your breast reduction surgery covered by insurance.
2. Document your symptoms.
When you come in for a consultation, we’ll ask you about how your breast size affects your life. To prepare for this consultation, some people find it helpful to make notes first. Here are some important factors to think about:
- Back pain
- Neck pain
- Posture issues
- Significant skin irritation
- Have you seen any other medical professionals because of conditions you believe are caused by the size of your breasts? This could include physical therapists, massage therapists, chiropractors, internal medicine doctors, or orthopedic surgeons
3. Schedule a consultation with us.
If wondering "will insurance cover my breast reduction?", a consultation is a great step. Your consultation will include detailed questions about what aspects of your life you feel are affected by having large breasts. Generally, insurance will not cover a breast reduction if your reasons are cosmetic. While we are happy to perform a breast reduction for cosmetic reasons, this is considered a self-pay procedure. If you feel the size of your breasts is causing you pain, interfering with your ability to stand with good posture, or leading to significant skin irritation – these may be considered by an insurance company to be appropriate medical reasons to have a breast reduction. The clinical term for large breasts that cause pain or obstacles to everyday life is symptomatic macromastia, and this is what an insurance company will be looking for, to decide whether your requested breast reduction is medically necessary. After your consultation, if we agree you are a candidate for insurance coverage for your breast reduction, we will help you with all the necessary paperwork.
4. Wait for an answer from the insurance company.
After the appropriate paperwork has been submitted, we need to wait for the insurance company to respond. If well-documented symptoms and reasons are submitted, we will hopefully get approval for the insurance coverage of your breast reduction. In some cases, the insurance company will deny the request. If this happens, it is not the end of the road. If you receive a denial, the next step is an appeal.
What if my insurance company denies coverage?
If the insurance company does not approve your request for coverage of your breast reduction, do not lose hope. This happens to many people, and the next step is an appeal. An appeal is a process where additional documentation and education are given to the insurance company. If your request is denied, it may have been that the insurance company needs more information about how the size of your breasts is interfering with your quality of life. We can help with this documentation. It can also be beneficial to get letters of support from any other healthcare processional who has treated you for problems related to your breast size. For example, if you have seen a physician about back pain – and they can attribute this to your breast size – a letter of support from that physician may help. Additionally, if you’ve seen a pain specialist or physical therapist, they may be able to provide additional evidence. Some patients also have the support of a dermatologist, if they’ve needed to see one for skin issues related to breast size.
6. Schedule surgery!
Once you are approved by your insurance to have a covered breast reduction operation, we can schedule your surgery. For most patients this operation takes a few hours, and many are able to go home the same day. If you are unable to have insurance cover your breast reduction surgery, and would still like to have this operation, please speak to us about financing options.
FAQs about insurance coverage of breast reduction:
Is a breast lift for large breasts, different from a breast reduction? Are both able to be covered by insurance?
While your breast reduction can be covered by insurance, generally a breast lift will not be. A breast lift usually just involves removal of skin, which allows us to return the breasts to a higher position. A breast reduction, on the other hand, involves removal of breast tissue, resulting in smaller sized breasts. For someone who has back pain or substantial skin irritation, a breast reduction is the preferable choice in most cases.
Will insurance cover my minor breast reduction, or only a reduction of a substantial amount of breast tissue?
In general insurance companies are more likely to cover a breast reduction that involves a substantial reduction in size. The more breast tissue the surgeon estimates they will remove, the easier it is to make the case that the size of your breasts are interfering with your life to an extent that you need a reduction. However, you should not ask for a bigger reduction than you’re comfortable with, just for insurance coverage. At your consultation, we can help you understand the amount of breast tissue that we would recommend removing.
What is the Schnur scale, and will my insurance company use it in their decision?
If you’ve been researching getting your breast reduction covered by insurance, you may have seen the Schnur scale. The Schnur scale was created in the early 1990’s, and is still used in many cases to help make the decision about whether a breast reduction should be covered by insurance. The scale uses the surface area of your skin to tell you the minimum amount of breast tissue you’d need removed to have the procedure covered by insurance. There can be some unfairness in this scale, however, because it tends to penalize people who are overweight or obese. Since many insurance companies still use the Schnur scale, we will show you what the scale would say in terms of whether the expected size of your breast reduction is ‘medically necessary’ according to insurance.
A breast reduction can notable improve the quality of life for many people. If you find that you have pain or substantial skin or posture issues related to the size of your breasts, you may be eligible for insurance to cover your breast reduction surgery. Our surgeons, office staff, and insurance team are experts at understanding the insurance approval process. Please contact us anytime if we can answer questions for you, or help you on the path to getting a breast reduction covered by insurance.