How much is a breast reduction with insurance?
Updated: Oct 19, 2022
Enlarged breasts, often known as macromastia, might have adverse health effects. Back, shoulder, and neck pain could result from the weight of the breasts. Some women develop persistent sores under the breasts or permanent shoulder grooves from bra straps.
Breast reduction surgery, also known as reduction mammoplasty, has psychological advantages in addition to treating physical issues like these. It can raise people's quality of life, sense of self, and perceptions of their bodies.
If you're considering reducing your breasts, you probably want to know how much surgery will cost and whether your insurance would cover it. Cosmetic breast reduction surgery is not covered under insurance. However, if you need the procedure for a medical condition, your health insurance may pay for it. The requirements for obtaining coverage for a breast reduction vary depending on your insurer.
Continue reading for more information on breast reduction surgery costs and when insurance will cover them.
Does health insurance cover breast reduction?
It varies. Breast reduction is only covered by health insurance if it is deemed medically required to treat persistent health issues.
This implies that you'll likely need to obtain insurance authorization before scheduling the breast reduction surgery. The insurance provider will ask your surgeon to submit certain medical information on your behalf, after which it will determine if you actually need the procedure. (You'll still have to pay copays or deductibles even if your insurance does cover the surgery.)
The insurance provider won't pay for breast reduction surgery if it doesn't match the medical necessity requirements of your health plan because it will be viewed as cosmetic.
How to obtain insurance coverage for a breast reduction
The procedure of getting approval for breast reduction surgery can be protracted and difficult. Insurance companies use various standards to determine whether a procedure is medically required.
Your health insurance policy might demand that:
a note from your doctor describing your symptoms and how long you've had them
records from your past medical treatments
Your stature and weight
images of your bust
Generally, you must present documentation proving that:
Your huge breasts are the cause of your ongoing health issues.
You've attempted further nonsurgical therapies
The nonsurgical therapies have not been effective.
Before providing coverage, several insurers demanded that a person be within 20% of their optimal body weight because weight loss on its own can result in smaller breasts. However, given that long-term weight loss is challenging and occasionally unachievable, some surgeons and scholars have questioned this criterion.
Your best course of action is to get in touch with your insurance as soon as you can and ask them to clarify all the requirements as well as the types of proof they would accept. You will then be aware of the precise documentation you need to compile and submit.
What qualifies as a medical need for a breast reduction?
Surgery must be deemed medically essential by a doctor. You might have to show the doctor and insurance proof that you've attempted unsuccessful nonsurgical therapies like physical therapy, weight loss, or musculoskeletal treatments in the past. The insurance provider might want evidence that you've experienced symptoms for at least six months.
Medical necessity for breast reduction surgery may be accepted by insurance carriers if:
You have difficult-to-treat skin infections or severe rashes.
Your range of motion is constrained.
Your nerves are compressed as a result of the weight of your breasts.
Your posture and spine alignment are greatly being impacted by the weight of your breasts.
You feel soreness in your breasts.
You feel pain in your shoulders, neck, or upper back.
Bra straps left grooves on your shoulders.
Do your breasts need to be a certain size to qualify you for a reduction?
Your breast size isn't really a factor when considering reduction surgery. The amount of tissue that needs to be removed is the major indicator. There may be a minimum amount of tissue that must be removed for the surgery to be considered "medically essential" by your insurance provider.
The Schnur Sliding Scale is a guideline used by some insurers. This ratio evaluates your body's overall surface area to the weight of the breast tissue that was removed. Although it is a typical guideline, this computation is not always an absolute rule.
Your surgery is typically regarded as being medically required if your Schnur ratio is higher than the 22nd percentile. It is regarded as cosmetic if it falls below the fifth percentile. If your ratio falls anywhere in the middle, it might be classified as either medical, cosmetic, or a combination of both, and insurers might or might not authorise it.
When having breasts reduced, how much weight is lost?
Depending on how your insurance provider defines it, there are different minimum amounts. Some may consider the surgery to be a breast lift rather than a breast reduction if less than 200–350 grammes (7–12 ounces) of breast tissue is removed. Since a breast lift is frequently regarded as cosmetic surgery, insurance does not typically cover it.
Do breast reductions get covered by Medicare?
No, never. Medicare does not provide coverage for cosmetic breast reduction surgery like private insurance do. When it is determined to be medically necessary, the procedure will be covered by both original Medicare and Medicare Advantage. However, a deductible, copay, or coinsurance will undoubtedly be required of you.
How much does a breast reduction cost with insurance?
The following items are included in the overall cost of breast reduction surgery:
cost of anaesthesia
Medications on prescription
According to the Aesthetic Plastic Surgery National Databank, the average breast reduction cost a plastic surgeon $5,717 in 2020. But prices vary widely based on things like:
Experience level of the surgeon
What method the surgeon employs for breast reduction
Whether you underwent surgery on one breast or both
Price trends in your area's market