Large breasts can often impact a woman’s quality of life. Bra strap irritation, back problems, and rashes are only a few of the symptoms women with large breasts can suffer from. These issues may also result in a diminished overall activity level.
Breast reduction surgery can help alleviate these symptoms not only by decreasing the weight of the breasts, but by creating a more ergonomic position of the breasts. Studies have shown that symptom relief does not directly correlate with the amount of absolute breast weight reduction. Even a small reduction in size with reshaping and replacement of breasts higher on the chest can result in symptomatic relief.
Does insurance cover breast reduction surgery?
Each insurance policy has different guidelines and exclusions. Insurers try to determine whether the patient’s motivation for breast surgery is cosmetic or functional by using specific criteria that need to be met before the procedure is considered medically necessary. These criteria usually include failed trial of non-surgical management for patient complaints. The following is a list of commonly requested supporting documentation for insurance coverage of breast reduction:
- Clear documentation of long-standing symptoms, including evaluation and treatment of neck, back, and shoulder pain.
- Documentation of consistent conservative management is also very important. This might include documentation of physical therapy, chiropractic care, the use of specialized support bras, and non-steroidal anti-inflammatory agents.
- For rashes, documentation of appropriate hygiene and utilization of appropriate medical treatment is essential.
- Medical records from the primary care physician and other providers (for example, psychiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request.
What other criteria do insurance carriers consider?
The amount of tissue removed is one of the more important criteria used by insurance carriers. This number varies from insurance carrier to insurance carrier. It’s often part of a height weight index, as a sliding scale.
As a patient’s weight increases, insurers generally require the removal of more breast tissue. Some companies request a fixed amount of weight to be removed for all patients to consider it medically necessary. Plastic surgeons estimate this number after consulting with the patient on their aesthetic desires, and balancing it with their functional needs.
For overweight or obese patients, a documented medically based attempt at weight loss is required. Often, it helps to document that weight loss did not result in reduction of breast size. If the breast reduction surgery is not authorized due to estimated amount to be removed, another patient consultation is undertaken to see if removal of greater amount of breast tissue may be acceptable to the patient with resultant smaller size.
If lack of supporting documentation is the case, then supporting letters from the patient’s physical therapist, massage therapist, and/or chiropractor are requested. If a patient desires breast reduction in spite of insurance denial, then they are given a price quote for cosmetic breast reduction. Some patients may qualify for financing through CareCredit.