Breast reduction surgery, commonly referred to as reduction mammaplasty, removes glandular tissue, excess fat and skin from breasts. Breast reduction surgery is done for several medically necessary reasons. Insurance companies have strict criteria in order to not consider this a cosmetic surgery; documentation along with pictures have to be submitted in order for the procedure to be covered as medically necessary.
Medical Necessity
Patients generally seek breast reduction due to physical discomfort caused by the weight of large breasts. According to the American Medical Association, reduction surgery is medically necessary if it is performed on an abnormal structure of the body to improve the body's function. Breast reduction is done on candidates for several different reasons, such as breasts are too large for the body frame; one breast is larger than the other; shoulder, back and neck pain from the weight of the breasts; skin irritation under the breasts; indentations from bra straps in the shoulder; heavy pendulous type breasts where nipples point downward; the inability to perform certain activities due to the size and weight of the breasts; and even being self-conscious of large breast size. Plastic surgeons generally perform breast reduction surgery. An evaluation will be done, which will document the reasons for needing a breast reduction. The surgeon's office staff can assist you in working with your insurance company to see if the breast reduction surgery will be covered as medically necessary.
Insurance Coverage
Obtaining approval from your insurance company can be a difficult process--if they cover the procedure at all. Most insurance companies have strict guidelines that must be met in order to have the procedure approved. For example, according to Aetna Insurance Company, a member must have at least two of the following symptoms for one year: pain in upper back, neck pain, shoulder pain, headaches or painful kyphosis (hunchback)--documented by x-rays, or bra straps cutting into shoulders. Members also must have photographs showing severe breast hypertrophy and have documentation from a physician stating that symptoms are primarily due to large breasts and the reduction will likely improve the chronic pain. Pain symptoms have to be documented for at least three months and the member must use supportive devices, medication and physical therapy. Another criteria the patient must meet is if she is over 40 years of age, she must have a mammogram performed within one year of the planned breast reduction surgery. The last criteria is based on Aetna's table of body surface versus weight removed from each breast. The patient must fall into the defined category. Some states are getting involved in mandated legislation to ensure that insurance companies must cover the procedure if it is medically necessary. For example, Maine has a law ensuring that coverage for breast reduction surgery is provided by insurance companies that operate within the state. The cost for breast reduction without insurance averages between $6,500 to $10,000.
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