Medical ProofWhen a patient seeks breast reduction surgery, one of the first steps the surgeon will take is to determine her candidacy. After a basic physical exam, the surgeon may find one or more characteristics such as:
- The breasts are excessively large for the patient’s frame
- Breasts are pendulous and heavy, causing rashes or redness in the breast crease or fold
- One breast appears to be larger than the other
- The patient has typical indentation marks on the top of each shoulder where bra straps have pressed into her skin for years
Standard ConsiderationsInsurance companies typically make the call by relying on a set of charts that consider height, weight, and the amount of removable tissue in each breast. If the amount of tissue to be removed meets the standard criteria of the insurer, the costs of surgery may be covered by them. Women with DD, DDD, and H cups usually qualify. However, it is important to note that each case is considered on its individual merit, and there is no guarantee that meeting the standard criteria alone will qualify the patient for insurance coverage. Even if the coverage is approved, the deductibles would have to be borne by the patient.
Tips for Patients
- Read your insurance policy terms and conditions carefully or check the insurer’s online resources for your specific type of health insurance to determine whether breast reduction is potentially covered.
- Call the insurer to check if pre-approval is required for breast reduction surgery.
- Ask the type of documentation the insurer requires from your surgeon as well as your family physician to establish medical necessity.
- If the insurer appreciates that medical symptoms arising from oversized breasts are likely to require ongoing expensive treatment, they will be more inclined to approve insurance coverage for breast reduction surgery.
- Find out if your insurance company requires a second medical or surgical opinion before approving coverage for your breast reduction.
- Check whether there is a possibility of combined coverage for breast reduction and breast lift, if you need to undergo both surgeries together.