Paul Sanchez
Whether or not medical insurance covers breast reduction surgery depends on a variety of factors. While some insurance plans have specific plan exclusions that do not cover breast reduction surgery in any case, many health insurance plans will cover the procedure if specific medical criteria are met. These criteria often include the demonstration that the procedure is medically necessary, which may be determined by the amount of breast tissue removed, the presence of certain symptoms, and the existence of a documented history of medical issues related to breast size.
| Characteristics | Values |
|---|---|
| Insurance coverage for breast reduction surgery | Covered by insurance companies if specific criteria are met |
| Criteria | Symptoms must be attributable to large breasts, non-surgical symptom management must be attempted first, a minimum amount of breast tissue must be removed, and other conditions depending on the insurance company |
| Examples of conditions that may qualify for coverage | Chronic pain in the neck, upper back, or shoulders, skin conditions or infections under the breast crease, nerve pain or numbness in the arms and hands due to breast weight, and restricted physical activity |
| Insurance plans | Some insurance plans have specific "plan exclusions" where breast reduction surgery is not covered in any case |
| Insurance company requirements | Proof that the surgery is being sought to alleviate health problems caused by excessively large breasts, documentation of symptoms and treatments, and a letter from the primary care physician |
| Schnur Scale | A reference ratio that compares the weight of the removed breast tissue with the total body surface area |
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What You'll Learn
Insurance companies may consider breast reduction surgery a cosmetic procedure
Breast reduction surgery is a procedure that involves the removal of skin, fat, and glandular tissue from the breasts to make them smaller and more proportionate to the body. While some individuals may seek this surgery for cosmetic reasons, others may have medical reasons for wanting the procedure.
The specific criteria for determining medical necessity can vary across insurance companies. Some companies may use the Schnur Sliding Scale, which compares the weight of the removed breast tissue to the individual's total body surface area. If the ratio is above the 22nd percentile, the surgery is typically deemed medically necessary, while a ratio below the 5th percentile is considered cosmetic. Ratios in between may be considered either medical or cosmetic or a mix of both.
Additionally, insurance companies often require documentation and treatment history from multiple specialists, such as physical therapists, chiropractors, dermatologists, or orthopedists, before approving coverage for breast reduction surgery. This process can be complex and time-consuming, and the specific requirements can vary from year to year. Therefore, it is essential for individuals considering breast reduction surgery to carefully review their insurance policies and consult with their providers to understand their specific coverage criteria.
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Medical necessity must be proven for insurance coverage
Breast reduction surgery is often deemed cosmetic and, therefore, not covered by insurance. However, if the procedure is deemed medically necessary, insurance companies may cover it. The criteria for medical necessity vary across insurance companies, but some common requirements include:
- Chronic health issues due to breast size: This includes physical symptoms such as severe rashes or skin infections, restricted physical activity, nerve compression, poor posture and spine alignment, and upper back, neck, or shoulder pain.
- Conservative (non-surgical) symptom management: Insurance companies may require documented proof of attempted alternative treatments, such as physical therapy, chiropractic sessions, or weight loss interventions, before considering surgery as a medically necessary option.
- Minimum amount of tissue removal: Some insurance companies dictate a minimum amount of breast tissue that must be removed for the procedure to be considered medically necessary. This is often determined using the Schnur Sliding Scale, which compares the weight of the removed tissue to the patient's total body surface area.
- Documentation and specialist referrals: Insurance companies often require extensive documentation of the patient's symptoms and treatment history. They may also request multiple reports from referred specialists, such as physical therapists, chiropractors, dermatologists, or orthopedists, to support the medical necessity of the procedure.
It is important to note that the criteria for medical necessity can vary significantly between insurance companies, and patients should carefully review their insurance policies and consult with their providers to understand the specific requirements for coverage.
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Pre-authorisation from the insurance company is required
To get insurance coverage for breast reduction surgery, pre-authorisation from the insurance company is required. This means that before scheduling the surgery, you will need to obtain approval from your insurance company. The process typically involves submitting the necessary documentation and meeting specific criteria to demonstrate medical necessity.
To initiate the pre-authorisation process, you should first contact your insurance carrier and request their criteria for coverage. Each insurance company has its own guidelines, and understanding these requirements beforehand is essential. Some insurance plans may have specific "plan exclusions" where breast reduction surgery is not covered under any circumstances.
As part of the pre-authorisation process, your insurance company will require you to submit health records and other relevant documentation. This typically includes evidence of chronic health issues caused by excessively large breasts, such as back, neck, or shoulder pain, skin conditions, nerve compression, or restricted physical activities. It is important to work closely with your healthcare providers to ensure that your medical records accurately reflect these symptoms and any non-surgical treatments you have attempted, such as physical therapy, medication, or custom bras.
Additionally, your surgeon may need to provide information on the amount of tissue to be removed during the procedure. Some insurance companies have a minimum volume or weight requirement, often calculated using the Schnur Scale or Schnur Sliding Scale, which compares the estimated amount of tissue removal to your total body surface area. Meeting this criterion is crucial, as insurance companies frequently consider it when determining whether the surgery is medically necessary.
It is important to note that the pre-authorisation process may take time and involve multiple submissions. Insurance companies often require thorough documentation and may deny initial requests. However, many people successfully appeal and secure coverage for this life-improving surgery. Therefore, it is essential to be persistent, provide comprehensive information, and work closely with your healthcare team and insurance carrier throughout the process.
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A minimum amount of breast tissue must be removed
For insurance companies, a breast reduction is usually considered a cosmetic procedure unless the patient can prove that they are suffering from several health issues caused by large breasts. This can include chronic pain in the neck, upper back, or shoulders, skin conditions or infections under the breast crease, nerve pain or numbness in the arms and hands, or restricted physical activity.
To prove medical necessity, insurance companies generally request 6-12 months of documentation and treatment by a physical therapist, chiropractor, dermatologist, or orthopedist before turning to surgery. This documentation should include photographic evidence of breast hypertrophy or overgrowth, as well as medical records demonstrating persistent symptoms in multiple areas of the body directly caused by heavy breasts.
The main measure used by insurance companies to determine whether breast reduction surgery is medically necessary is the amount of tissue to be removed. This is calculated using the Schnur Sliding Scale, which compares the weight of the removed breast tissue with the patient's total body surface area. Typically, if the Schnur ratio is above the 22nd percentile, the surgery is considered medically necessary, while a ratio below the 5th percentile is considered cosmetic. The minimum amount of tissue that must be removed varies according to the insurance carrier's definition, with some insurers requiring a minimum of 200-350 grams (7-12 ounces) of tissue to be removed for the procedure to be considered a breast reduction rather than a breast lift.
It is important to note that the criteria for medical necessity can vary between insurance companies, and patients should carefully review their insurance policy and contact their insurer to understand all the requirements and documentation needed for coverage.
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Non-surgical treatments must be attempted first
While breast reduction surgery can be considered a cosmetic procedure, it is often deemed medically necessary for patients with excessively large breasts that are causing health issues. In such cases, the procedure may be covered by insurance companies, but only if specific criteria are met. These criteria vary across insurance providers, but they generally require proof of medical necessity and may include a documented history of non-surgical treatments.
As such, it is important to understand the specific requirements of your insurance company before assuming that breast reduction surgery will be covered. Patients should carefully review their insurance policy and be prepared to meet the outlined criteria when submitting their claim. This may include providing a detailed record of symptoms and treatments, including non-surgical interventions, that have been attempted to address the issues related to breast size.
Non-surgical treatments that may be considered before breast reduction surgery include conservative management of rashes and skin infections under the breasts. This can involve the use of baby powder, diaper rash ointment, or medicated creams such as steroid ointment. Patients may also explore physical therapy, pain medication, chiropractic care, or custom bras to alleviate symptoms such as back, neck, or shoulder pain, nerve compression, and poor posture.
It is important to note that insurance companies often require documentation of these non-surgical treatments, including reports from referred specialists and treatment history from healthcare providers. This documentation serves as evidence that non-surgical approaches have been attempted without success, supporting the medical necessity of the breast reduction surgery. By working closely with healthcare providers and gathering the necessary documentation, patients can strengthen their case for insurance coverage.
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Frequently asked questions
It depends on the insurance company and the patient's medical history. Breast reduction surgery for cosmetic reasons doesn't qualify for coverage. However, if you're getting the surgery for medical reasons, your health insurance may cover it.
Insurance companies have different criteria for whether breast reduction surgery is medically necessary. Some common criteria are:
- Severe rashes or skin infections that are hard to treat
- Restricted physical activities
- Nerve compression due to the weight of the breasts
- Poor posture and spine alignment
- Chronic pain in the breasts, neck, upper back, or shoulders
To increase your chances of getting insurance coverage, you should work closely with your healthcare providers and submit a strong case demonstrating that the procedure is medically necessary. Keep thorough records of all symptoms and treatments related to your issues.
Some non-surgical treatments that patients may need to attempt before qualifying for breast reduction surgery are:
- Baby powder, diaper rash ointment, or other medicated creams such as steroid ointment for rashes under the breasts
- Physical therapy
- Pain medication
- Chiropractic care
- Custom bras
Some insurance companies that cover breast reduction surgery are:
- United Healthcare
- Anthem Blue Cross
- Aetna
- Cigna
- Blue Shield of California
