When Does Insurance Cover Breast Reduction Surgery?
Key takeaways:
Health insurance does not cover cosmetic breast reduction, but plans usually cover breast reduction surgery that is medically necessary.
Health insurance companies set criteria that determines whether a breast reduction is medically necessary. Procedures that are done to relieve shoulder pain or to create symmetry between breasts after cancer surgery often meet this criteria.
To get your insurance plan to cover a breast reduction, you typically need to have a documented chronic health condition that’s related to your breast size.
Table of contents
Breast reduction surgery — also called reduction mammoplasty — can remedy physical symptoms as well as have psychological benefits. The procedure, which involves removing excess breast tissue, can improve quality of life, self-esteem, and body image.
Insurance generally covers breast reductions that are medically necessary, but not procedures done for cosmetic reasons. If you're considering a breast reduction, you're probably wondering how much your procedure will cost and whether it will be covered by health insurance. Find out answers to these questions and more, below.
Reasons for breast reduction surgery
Reasons why people need or want breast reduction surgery include:
Macromastia: Very large breasts — sometimes called macromastia — can cause physical pain as well as emotional distress and poorer quality of life. The weight of the breasts may lead to pain in the back, shoulders, and/or neck. Some women also have permanent shoulder grooves caused by bra straps or recurrent rashes under the breasts.
Gigantomastia: This rare condition causes some women to develop excessively large breasts. Gigantomastia is often caused by puberty, pregnancy, or medications.
Gynecomastia: Overdevelopment or enlargement of breast tissue in males is called gynecomastia.
Chest masculinization: When breast reduction is used for gender affirmation, it is also called top surgery or chest masculinization.
Symmetry after mastectomy: Reduction of one or both breasts can create symmetry following breast cancer surgery.
Cosmetic reasons: This is a breast reduction for appearance only.
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Is breast reduction covered by health insurance?
Health insurance covers breast reductions that are considered medically necessary to treat chronic health symptoms. These symptoms may include:
Chronic back, neck, and/or shoulder pain
Arthritis in the spine
Shoulder grooves with skin irritation related to supportive garments
Skin issues such as inflammation, infection, bleeding, chronic moisture, and/or rashes
In order to get insurance to cover your breast reduction surgery, you’ll probably have to get a prior authorization before you schedule the procedure. This means your surgeon will need to send your insurance company your health records and other documentation that explains why the procedure is medically necessary.
If the procedure doesn't meet your health plan’s criteria for being medically necessary, your breast reduction will be considered cosmetic and won't be covered.
How to get a breast reduction covered by insurance
Getting coverage approval for breast reduction surgery can require thorough documentation and persistence. As mentioned earlier, health insurance plans typically have criteria to determine if a procedure is medically necessary.
Your health insurance plan may require:
A letter from your physician detailing your symptoms and how long you've had them
Your medical records, which should include information about any previous treatments as well as other information, such as your height and weight
Photos and/or descriptions of your breasts
Saving without insurance: Here are our best tips from a personal finance expert on how to make breast reduction surgery more affordable with or without insurance.
Does Medicare cover breast reductions? Maybe. Find out when Medicare will cover breast reductions. We’ll also break down any potential out-of-pocket costs.
Can I use my HSA to pay for breast reduction surgery? Find out if you can use health savings account (HSA) funds to pay for cosmetic procedures tax-free.
You'll generally have to provide records showing that:
You have chronic health symptoms caused by having large breasts.
You have tried nonsurgical treatments for your symptoms.
Nonsurgical treatments have not helped.
Weight requirement for breast reduction
Typically, the amount of breast tissue the surgeon plans to remove compared to your height and weight is the calculation health plans use to determine if a breast reduction surgery is medically necessary or cosmetic. In the past, some health plans have required a person to be within 20% of their ideal body weight before approving coverage, as weight loss can cause the breasts to become smaller. However, this requirement has been questioned by some surgeons and academics, given that achieving lasting weight loss is difficult and sometimes unrealistic.
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Your best bet is to contact your insurance company as early as possible to get an explanation of all of the requirements for getting the surgery covered, including any necessary documentation. That way, you'll know what to gather and submit.
What makes a breast reduction medically necessary?
A surgeon must determine that your breast reduction is medically necessary to get coverage. You may need to provide evidence to your surgeon and health plan that you’ve tried nonsurgical treatments — such as physical therapy or weight loss — without success. Your health plan may also want proof that you have experienced symptoms for at least 6 months.
Your insurance company may approve coverage for your breast reduction surgery if you have one or more of these conditions:
Severe rashes or skin infections that are hard to treat
Restricted physical activity
Nerve compression due to the weight of the breasts
Posture problems and spine misalignments because of the weight of the breasts
Back, neck, and/or shoulder pain
Shoulder grooves from supportive garments
Do your breasts have to be a certain size in order for you to be a candidate for reduction?
Along with your symptoms, breast size in relation to your body size can factor into whether insurance will cover your breast reduction surgery. Some health plans have requirements about the amount of tissue to be removed for the procedure to be considered medically necessary.
Some health plans use the Schnur Sliding Scale as a guideline for medical necessity, though most experts consider this evaluation method outdated, inaccurate, and a potentially poor predictor of symptom relief. The Schnur method compares the weight of the breast tissue that is expected to be removed with a person’s total body surface area. Typically, scores above the 22nd percentile indicate medical necessity, while those below the 5th percentile are considered cosmetic. If you score in between these percentiles, your procedure may or may not be approved.
How much weight is removed during breast reduction?
The minimum weight that needs to be removed to qualify for surgery depends on the size of your breasts and your body size. For some insurance plans, if the amount of breast tissue removed is less than 200 g to 350 g (7 oz to 12 oz), the procedure may be considered cosmetic. Other insurance plans require the intended removal to be at least 500 g (about 18 oz) for a procedure to be considered medically necessary.
Does Medicare pay for breast reduction?
Medicare covers breast reduction surgery that is deemed medically necessary. This is true for original Medicare and Medicare Advantage.
For your procedure to be covered, you must have symptoms related to having large breasts that have interfered with your normal activities for at least 6 months.
How much does a breast reduction cost with insurance?
The out-of-pocket costs of your breast reduction surgery with insurance will depend on your health plan. Your cost-sharing responsibilities are outlined in your summary of benefits and coverage, known as the SBC, which includes information on any:
It’s important to note that you may receive several bills for your surgery, such as charges from your surgeon, your surgical facility, and the healthcare professional who administered your anesthesia.
How much does breast reduction surgery cost without insurance?
The cost of breast reduction surgery varies widely. The price without insurance can range from less than $5,000 to $19,000 or more.
MDsave, a healthcare price-shopping tool, estimates the procedure’s average cost in the U.S. at nearly $12,000. CareCredit, a healthcare financing company, estimates an average cost range of around $3,000 to $19,000.
Fees and other costs
The American Society of Plastic Surgeons reports the average surgeon's fee for a cosmetic breast reduction is about $6,800 among its members.
But, in addition to the surgeon’s fee, you may have other costs related to breast reduction surgery, including:
Anesthesia
Hospital or facility fees
Diagnostic testing like a mammogram
Post-surgery recovery garments
Prescription medications
It’s important to note that women who are age 40 or older typically need to provide a current mammogram to their surgeon before the procedure. But this can be a requirement regardless of age.
How can I afford a breast reduction without insurance?
If you don't have health insurance, here are strategies to make breast reduction surgery more affordable:
Shop online. Use price estimation tools to calculate costs at different facilities. Hospital price transparency rules now require facilities to publish standard charges for services.
Ask for a good faith estimate (GFE). If you are self-pay or uninsured, you can ask for a GFE from the hospital or surgical center where you have the procedure. Your final bill should be within $400 of the GFE. If it is higher, you can ask the facility or provider to match the amount on the GFE.
Research financing options. Many surgeons work with healthcare financing companies or accept medical credit cards so you can pay over time.
Ask about payment plans. Your surgeon’s practice may offer payment plans to help you afford breast reduction surgery. Also check your eligibility for financial assistance programs.
The bottom line
Breast reduction surgery is covered by health insurance when it’s medically necessary. Proving the medical necessity of your procedure to your health plan can be complicated and require documentation from your healthcare professional. But getting insurance to cover your breast reduction can save you a significant amount.
Why trust our experts?
References
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