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When Does Insurance Cover Breast Reduction?

Breast reduction surgery can be a necessary medical procedure and therefore covered under your insurance policy. It is important to realize you will face an uphill battle in getting your insurer to cover the procedure, so you need to fully understand the process to qualify for benefits. You will also need to be prepared to argue for your best interest and actively engage your insurer for results. If you do these things, insurance may cover your breast reduction given certain qualifying factors.

Covered in Your Insurance Policy

Not all insurance policies will cover this type of surgery regardless of the steps you take. You will have to review your policy to determine if breast reduction, cosmetic surgery or elective surgery may be covered. Insurers today often acknowledge the decreased cost of performing a one-time surgery over a lifetime of alternative consequences. If you are not covered under your current plan, you may look for better coverage for your unique needs. 

Medically Necessary as Determined by a Physician

Non-emergency surgeries must be performed at the recommendation of a physician in order to receive an insurance reimbursement. You will have to meet with at least a primary care specialist for the referral. It will likely also be necessary for you to meet with a specialist to determine if the reconstructive surgery is necessary. Your insurance may ask you to go through physical therapy for back or shoulder pain before approving a breast reduction. Since breast surgery is often considered plastic surgery instead of necessary surgery, you will have to follow these steps to assure this is being done for medical rather than aesthetic reasons. Plastic surgery procedures, such as a rhinoplasty in the case of a deviated septum, can still be covered by insurance when recommended by a doctor.

Performed to Specifications

Even once an insurance company agrees to cover your breast reduction surgery, your surgeon will have to follow certain specifications. For example, if your surgeon would like to also lift your breasts or use an implant to reconstruct the breasts, then you will potentially have to cover this portion of the procedure out of pocket. Your insurance policy will typically cover either a percentage of or a maximum claim amount on this claim. When your surgeon bills you for more than this amount, it will be up to you to make up the difference. 

Preventative Breast Reduction

If you are predisposed to breast cancer due to family history, you may qualify for a breast reduction surgery or breast reduction mammaplasty even if your breasts do not cause you daily problems. This preventative measure is a life-changing event, and it should be thoughtfully considered prior to taking the next step. However, your insurance may encourage or cover the procedure for you in order to potentially prevent cancer from forming in your breast tissue. In this case, the insurance may even cover the reconstructive surgery necessary to place implants after your breasts have been removed. Your insurance company will need to have sufficient reason to believe you are heavily predisposed or even show pre-cancer markers in order to approve this action.


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