Breast Reduction Insurance Requirements

Posted By on Sep 28, 2015 in Breast Reduction, Covered By Insurance, insurance, Plastic Surgeon, Plastic Surgery Blogs | 0 comments


For some women, breast reduction is not a cosmetic plastic surgery, but rather a medically necessary procedure to address their neck and back pain, postural problem, non-healing skin irritation along the inframammary crease, and other symptoms of disproportionately large breasts.

While this procedure is usually covered by insurance, the requirements are becoming more and more restrictive. Nevertheless, a board-certified plastic surgeon who regularly performs the surgery can help you get pre-approval as he is familiar with the “process.”

breast-reduction-insurance-requirements

Los Angeles plastic surgeon Dr. Tarick Smaili says breast reduction insurance requirements differ from issuer to issuer, and state to state. Nevertheless, they have common “denominators” such as:

  1. Extreme downsizing. The problem with this requirement is that some patients might be forced to get too much reduction just to satisfy their insurance issuer, leading to breasts that are too small for their liking.

However, even some reductions may relieve symptoms such as back and neck pain, rounded shoulder, and headaches. This is particularly true of petite women whose breasts are too large in proportion to their body.

  1. Proportion of the breast size to the body. This requirement is less restrictive as it allows smaller reductions because the patient’s height and weight are taken into account.
  1. Strict numbers. A growing number of health insurance issuers are becoming stricter when it comes to breast reduction coverage that some will only pay if the weight of the removed soft tissue is at least 500 grams per breast. This could pose a problem in small-framed women with overlarge cup size.
  1. Medical evidence. The more medical evidence a patient is able to present, the higher the chance of pre-approval. The general rule of thumb is to secure letters and recommendations from experts—such as board-certified plastic surgeon, chiropractor, internist, and orthopedic surgeon—attesting that the surgery can relieve one’s physical symptoms.
  1. Alternative non-surgical treatments. It is not uncommon for health insurance issuers to require policyholders to have tried weight loss and physical therapy first; however, this is a “tricky” requirement since women with overlarge breasts find it hard, if not too painful, to perform even the easiest exercise.

Nevertheless, it remains helpful to be near one’s normal weight prior to breast reduction or any type of body contouring procedure because it is easier to predict the results, particularly the proportion of the breast to the body frame.

Despite the challenges of securing insurance pre-approval, Dr. Smaili says a patient can always demand an appeal if the first request is denied.

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