Health insurance is complicated, and many people find themselves unaware of what is or is not covered by their insurance. There are many types of insurance coverage, and different policies will cover different things. Ultimately, the question of whether any particular procedure will be covered under insurance is something that will need to be discussed with your healthcare provider. Nevertheless, some basic guidelines will apply across most insurers.

In general, insurance companies are interested in keeping their operating costs low. By approving as few claims as possible, they can maintain high profits. This means that insurance companies are usually unwilling to cover procedures that are viewed as being medically unnecessary or purely cosmetic. On the other hand, insurance companies are eager to pay for preventative care as a way to reduce the cost of future medical expenses. This means that patients who can prove that their procedures are medically necessary and will prevent future concerns will have an easier time getting their expenses paid.

What is Breast Reduction Surgery?

Some women with large breasts experience substantial pain or discomfort related to their breast size. Some common complaints include back pain, reduced flexibility and chronic headaches. In some cases, women may also have breasts that are of two vastly different sizes; this can cause unique health problems as well.

During a breast reduction surgery, a plastic surgeon will make one or more incisions in the breast tissue and remove fat from the inside of the breast. The breast itself may need to be reshaped, and the nipples or areolas may be moved. In some cases, temporary or permanent implants may also be necessary to maintain the appropriate shape of the newly reduced breast. Any excess skin will be removed, and the incisions will be closed with stitches.

The procedure usually takes from three to five hours, and it is generally performed as an outpatient procedure. Follow-up care will include pain management and checkups to ensure that additional procedures will not be necessary.

Will Health Insurance Pay for Breast Reduction?

It is possible to get your insurance to pay for a breast reduction surgery if you can prove that the surgery is medically necessary. The first step to this is speaking with your primary care physician. When first approaching the doctor, be sure to explain any complaints you have. Focus on medical complaints rather than anything that could be construed as cosmetic. For example, mention your back pain or sores from ill-fitting bra straps; also mention if your breast size makes it difficult to exercise or otherwise maintain your health.

Insurance companies will base the decision on whether a breast reduction surgery is medically necessary on several factors:

  • The medical complaints of the patient
  • The amount of breast tissue that can and will be removed during surgery
  • The ratio of a woman’s breast size to other parts of her body
  • Whether any other non-invasive procedures could take care of the problem, such as specially fitted bras or general weight loss

After conferring with your doctor about the possible of a breast reduction procedure, the doctor will most likely provide you with non-surgical methods to attempt first. This may include prescription pain killers or other drugs to help with back problems or other concerns. Be sure to fill these prescriptions and report back if they do not solve the problem.

Once it has been confirmed that your breast reduction surgery is necessary, you will need to get a referral to a plastic surgeon who can do the procedure. You’ll want to ensure that the surgeon is in your insurance company’s preferred network. In some cases, an insurance company will cover a referral even if the surgeon is not in the network, but this is something you will need to confirm with your insurance company.

What if My Insurance Company Won’t Pay For the Surgery?

Some insurance policies will have named exclusions. If breast reduction surgery is excluded under your policy, you may not be able to get coverage for it even if the procedure is medically necessary. Most insurance companies will have an appeals process, but there are no guarantees that your appeal will be accepted.

If your insurance company refuses to cover your breast reduction surgery, you may still have some options. Meet with several surgeons and see if any are willing to offer a payment program or work with you to reduce the cost of the procedure. Getting the surgery you need may be possible even without the help of insurance.

Nevertheless, if you follow the guidelines above, your odds of getting your breast reduction surgery covered by insurance are higher than they may otherwise be. If you have any other questions about the way your insurance policy operates, you can contact the company for clarification.