Will Health Insurance Pay for a Breast Reduction?

Macromastia, the medical term for abnormally large breasts, can cause a number of complications. Neck and back pain, posture issues, are some of the problems that women with cumbersome breasts have reported; they can also make it difficult to participate in certain activities and cause embarrassment. For women who are experiencing issues as a result of macromastia, reduction surgery is an option.

What is Breast Reduction Surgery?

Reduction mammoplasty, or breast reduction surgery, is a surgical procedure aims to correct macromastia and the problems that are associated it. The procedure involves removing skin and tissue from the breasts in order to minimize their size and reshape them. In cases where the only fatty tissue is being removed, liposuction may be performed in order to reduce the size of the breasts.

For women who experience problems as a result of their abnormally large breasts, reduction surgery can offer a number of benefits. It can minimize pain, improve posture, reduce limitations, and improve appearance.

What to Expect

The procedure is usually done under general anesthesia; however, if the reduction is minimal, local anesthesia may be used. It can take between three and five hours to complete, and usually, it is done as an outpatient procedure, meaning that patients are able to go home the same day. There is no need for a long hospital stay. Recovery varies from person to person, though some pain is to be expected and medications can be used to ease any discomfort. Bruising and swelling are not unusual and can last for a few weeks. Until the breasts are fully healed, activities will likely need to be limited; for example, strenuous exercise and heavy lifting should be avoided. Healing can take a month or more.

Is the Procedure Covered by Health Insurance?

If you are considering breast reduction surgery, you are likely wondering if the procedure will be covered by your health insurance. It depends on the specifics of your procedure and why you are having it done. If it is considered cosmetic, meaning that it is only being done to improve your appearance, it is likely that your insurance will not cover the procedure. However, if it is medically necessary, your policy may cover the cost.

In order to have your health insurance cover breast reduction surgery, you need to establish that you are suffering from a number of health problems as a result of your overly large breasts; for example, if they are causing you an extensive amount of pain, have impeded your abilities to properly function in regular activities, and have damaged your posture, the procedure may be covered by your insurance company. Additionally, you will likely have to prove that you have attempted to mediate the problems that you have experienced with other tactics, and that those tactics have failed.

To prove medical necessity, you will likely be required to provide your insurance company with reports from medical professionals that prove you have attempted other methods to alleviate the problems that you are experiencing as a result of your large breasts. For example, you may need to offer documentation from an orthopedist, a chiropractor, and/or a physical therapist, in addition to your general practitioner. Additionally, that documentation will likely need to be lengthy; for instance, it will need to establish that you have been seeking treatment for a prolonged period of time (up to a year), and that treatment has provided minimal or no results.

How to Find Out if Your Health Insurance will Cover Breast Reduction Surgery

If you are suffering from serious, chronic issues as a result of macromastia and are considering breast reduction surgery to correct those problems that you are experiencing, make sure to speak to your health insurance company. It’s important to find out if your policy offers coverage for the procedure. Ask your carrier to send you, in writing, the details of your policy and what it covers. Don’t assume that just because someone you know had a breast reduction and the procedure was covered by her policy that your policy will cover yours. Every insurance company – and every policy – has different criteria regarding what is covered. If your health insurance does cover the surgery, it will still take time to make arrangements to have the procedure covered. Make sure to have your primary care physician and any other specialists that you have worked with, as well as the surgeon who will be conducting your breast reduction surgery, provide all of the necessary documentation regarding the issues you are experiencing. More than likely, you will be required to submit the documentation to your health insurance company in order to have the procedure covered.

If your policy does not provide coverage for breast reduction surgery, speak to an agent that specializes in health insurance to find out if there are policies that do offer coverage and consider obtaining new coverage.