It seems like a simple question. “Is breast reduction surgery covered by health insurance?” But the answer can be very complicated and involve many variables. It is typically considered a cosmetic procedure until the patient can show an adequate number of related health issues and attempted remediation prior to undergoing corrective surgery.
Once the threshold has been reached, the insurance company may then consider breast reduction a reconstructive procedure. The problem is that the threshold can be different for every insurance company reviewer. Breast reduction surgery, also known as reduction mammaplasty, is a corrective treatment of symptomatic macromastia (large breasts). Symptoms related to macromastia are neck, shoulder and back pain and may include breast pain and dermatitis or rashes beneath the breasts.
“Patients are often referred to plastic surgeons by other physicians recommending evaluation for breast reduction due to symptoms like persistent neck, back and shoulder discomfort, as well as bra strap grooving and intertriginous moisture and rashes that have failed medical management,” said Jeffrey Janis, MD, president of the American Society of Plastic Surgeons and Chief of Plastic Surgery, University Hospital at The Ohio State University Wexner Medical Center. “Unfortunately, the patient can be under the mistaken impression that because she received a referral, that the surgery is automatically covered by her insurance plan.”
For many procedures, a lack of treatment history might not be an issue. However, for breast reduction, which can be considered cosmetic or reconstructive, depending on the patient – and the insurer’s review – the lack of history could prove problematic.
“Male and female patients seeking breast reduction surgery must prove to their insurance provider that they have pursued other medical treatments or sought previous consultations concerning macromastia,” said ASPS member Stephen Chidyllo, MD, West Long Branch, N.J. “The patient may also need to indicate a history of physical therapy referrals, chiropractic treatment, an orthopedic consultation or a dermatology exam.”
“In my experience, insurance companies frequently require two to three documented reports from other referred specialists before they’ll consider covering it,” said Dr. Chidyllo. “Also, the insurance companies commonly request six to 12 months of documentation and treatment by either a physical therapist, chiropractor, dermatologist or orthopedist.”
Keep yourself updated on policies during this process, as an insurance company’s criteria might not be the same year after year. Candidates for breast reduction surgery who are interested in requesting health insurance coverage should contact their health insurance carrier and have them forward in writing their criteria for coverage. Every insurance company has different, independent criteria and indications.
The American Society of Plastic Surgeons (ASPS) is the world’s largest organization of board-certified plastic surgeons. Representing more than 7,000 Member Surgeons, the Society is recognized as a leading authority and information source on aesthetic and reconstructive plastic surgery. ASPS comprises more than 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the Society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada. ASPS advances quality care to plastic surgery patients by encouraging high standards of training, ethics, physician practice and research in plastic surgery.