Breast reduction surgery is an excellent solution for women seeking to address disproportionately large breasts. Whether to treat back or neck pain, correct skin irritation or enhance your physique, reduction mammoplasty has helped countless women achieve a slimmer and more comfortable breast contour that is more proportional to their figure and supports the health of the rest of their body. At Austin Plastic & Reconstructive Surgery, one of the most common queries raised by breast reduction patients is:
WILL MY HEALTH INSURANCE COVER THE COST?
The answer is often yes. However, this will depend on the extent of coverage offered by your health insurance provider. Most providers will have a number of requirements that patients must meet in order to demonstrate that the procedure is medically necessary for your health. Since this process could take several months, it is crucial to consult with your physician and healthcare provider as soon as symptoms occur.
CLINICAL PROBLEMS
Breast hypertrophy is a medical condition that occurs due to the excessive development of glandular tissue. This issue can arise during puberty, secondary to weight gain or as a result of the aging process, where fat deposits naturally shift. Hyperplasia or macromastia refers to the excessive growth of mammary tissue, which often occurs as a result of pregnancy and hormonal changes. These conditions can lead to significantly asymmetrical, overly large or disproportionate breasts that encourage many women to consider reduction mammoplasty. At Austin Plastic & Reconstructive Surgery, we see women of all breast shapes, sizes and concerns seeking medical help for their symptoms. Our compassionate surgeons encourage anyone experiencing these problems to schedule a consultation and learn more about their suitability to undergo breast reduction surgery.
SYMPTOMS THAT MAY QUALIFY YOU FOR A MEDICAL BREAST REDUCTION
To qualify for insurance coverage, patients must have documentation by their primary care physician regarding treatment of persistent symptoms, typically for at least 6 months or more. Though symptoms can vary for each individual, the most common problems experienced due to disproportionately large breasts can include:
- Pain in the back, shoulders or neck
- Shoulder “grooving” from bras
- Skin irritation, rashes, infection or ulceration
- Kyphosis (curved spine)
- Headaches
Before considering breast reduction surgery, your primary care physician, OB/GYN, orthopedist or other medical provider should first prescribe alternate, non-surgical methods for improving your condition, depending on the symptoms you are experiencing. For instance, women suffering back, shoulder or neck pain typically benefit from physical therapy which helps improve posture by strengthen the back muscles. It is recommended that you undergo at least 6 weeks of physical therapy for these symptoms, as it can improve your insurance coverage qualifications. Patients suffering from skin irritation or rashes under their breasts are required to have documentation of medical treatment of these symptoms by their primary care provider to qualify for a medical breast reduction.
To be eligible for surgical intervention, you will need to provide documented proof that you have sought alternative methods for a minimum of six months to address the pain, discomfort or irritation caused by excess weight in the breasts, as well as have had a clear mammogram within a year of your projected surgery date. Because of this, it is vital to discuss your symptoms with a medical provider as soon as you experience them, and then pursue non-surgical treatment to build your medical history and, if needed, get a mammogram. Once you are ready to seek surgery, you will discuss your primary concerns and help determine whether you are more suited to a cosmetic or insurance breast reduction.
COSMETIC VS INSURANCE BREAST REDUCTION
Breast reduction surgery is often considered a multi-purpose treatment. In a reconstructive sense, the procedure aims to remove excess tissue to resolve pain or irritation and restore comfort to your body, making it easier to perform daily tasks and engage in exercise. However, many patients also expect aesthetically pleasing results that complement their body. It’s important to be aware that your aesthetic goals will also determine whether you qualify for insurance coverage. Insurance providers require a minimum amount of tissue removed from each breast based on your total body surface area in order for you to qualify for insurance coverage, which may not result in the aesthetic results you are after. In this case, a cosmetic breast reduction would be more suitable.
If you are seeking to have the costs covered, insurance carriers will thoroughly investigate your situation to ensure the procedure is medically necessary. As described above, this takes more than six months of preparation and will include consultations with other healthcare providers and alternative treatment methods. Before approving you for surgery, insurance companies will require letters on letterhead from the medical professionals you have sought non-surgical treatment with regarding your condition and your efforts to resolve symptoms.
Christine Fisher MD
