Breast reduction surgery is an investment in your health, but also of your time and in many cases of your finances. If you’re experiencing pain or limitations in your activities due to overly large or heavy breasts, it’s natural to wonder if you can rely upon your health insurance to cover it–or to help with the costs.
We’ve spoken with many patients who wonder the same thing.
Overall the exact answer will vary from patient to patient, however below is some helpful advice we’ve gleaned from our experiences here in Bergen County. It can give you an idea of what to expect from health insurance for a breast reduction.
Health Insurance May Cover Breast Reduction
There are many cases where health insurance covers some or all of the costs of a breast reduction. With that said, health insurance typically does not cover cosmetic plastic surgery, except to restore the body to proper function after an injury, to repair certain function-impairing birth defects and for reconstruction of one or both breasts after a mastectomy. The important distinction is which reduction is cosmetic and which is medically necessary.
Some insurers may cover breast reduction surgery for those who have documented health problems that can be attributed to large or heavy breasts.
The size of the planned reduction will be taken into account as well as symptoms including back, neck or shoulder pain, spine problems, skin rashes or infections, and nerve damage. An insurance company may ask for verifying documentation such as photos, evaluation from orthopedic surgeon or dermatologist. Before obtaining these you should seek a consult with a plastic surgeon.
Health insurance companies tend to vary greatly in what they agree to cover, so you need to check carefully and not assume anything. As you may be aware, some insurance providers may cover a test, treatment or surgical procedure under one type of plan and not under another.
Insurance may or may not cover blood testing, mammography or the physical examination that must be done before your breast reduction.To further complicate matters, insurance plans may cover varying percentages of health costs that they approve, according to their own regulations and guidelines.
Many restrict your treatments to certain doctors and many require pre-authorization of your procedure. (The advantage to this is that you have a better picture of whether your breast reduction meets their requirements for coverage–and what your costs will be.)
Under health plans that assign you a primary care doctor to manage or coordinate your healthcare, like HMOs, you might have to ask your primary care provider for a referral to a specialist/plastic surgeon first.
How Do Health Insurers Decide What to Cover?
In general, insurance companies base their treatment coverage decisions upon whether the surgery is medically necessary or optional. If a surgery meets the specific company’s requirements as medically necessary for your health, they may pay for all or part of a treatment. Insurance companies will typically refuse to pay for any purely cosmetic surgery.
Plastic and Reconstructive Surgery’s recent research showed that insurance carrier’s breast reduction standards are not necessarily in line with medical science and professional opinions.
Getting an Answer from Your Insurance Company
Your plastic surgeon or their office staff should help you navigate the question of insurance coverage. You should always get a definitive answer before going forward with breast reduction surgery, if you’re relying on your insurance company to pay for some of the cost. Some tips that breast reduction patients have shared with us in the past include:
- For your peace of mind, research your insurance company’s policies in advance and get their written pre-approval, or pre-authorization, if possible.
- Do not assume you’re covered because a friend or family member was covered for breast reduction surgery (even under the same insurance plan as you have.)
- Do not interpret the insurance company’s written rules, guidelines and materials for yourself. You’re just crossing your fingers by assuming anything based on the general wording. It’s essential to have permission for your specific case. If you were to go forward without getting a pre-approval, you’d have to be prepared to get a denial of your claim and have a back up plan or budget in place.
First Find Out if You’re A Good Candidate for Surgery
During your consultation with a New Jersey plastic surgeon, you’ll discuss your medical history and you’ll also be asked why you’re seeking a breast reduction. Be completely honest with your physician.
They will need to determine if you are a good candidate for breast reduction surgery, both physically and emotionally, before any talk about the potential costs can begin. If you are a smoker, or have chronic medical conditions, you may not be a good candidate. However, there is no single attribute that will disqualify you, so it is wise to visit with a surgeon for a no-charge consultation about the procedure to learn more about your specific case.
Discuss Your Breast Reduction with a Plastic Surgeon in NJ
The first step in the breast reduction process is to meet with a breast reduction surgeon in NJ to discuss the surgery. You will be able to learn about the surgery, if you’re a great fit and what the next steps are.
Our Aesthetic and Reconstructive Surgeons are dedicated to your health and well-being. We are available to answer your questions and determine if you’re a good candidate for surgery. If we believe you’re a good candidate and you’ve made a decision to move forward, we’re happy to send any required information to your insurance company.
We recommend putting cost considerations out of your mind until you discuss your specific case with one of our dedicated surgeons. We want you to concentrate on doing what is best for your physical and emotional health.
