Is breast reduction surgery covered by insurance?
Breast reduction surgery, or reduction mammoplasty, may not get as much attention as breast augmentation surgery but it is actually one of the more common types of procedures performed by plastic surgeons. Generally, in breast reduction surgery, excess fat, glandular tissue and skin are removed in order for the patient to have breasts that are more proportional in size with the rest of the body.
Women consider breast reduction procedures for a variety of reasons; some physical and others more emotional. Breasts that are overly large are also heavy, which can result in stress and discomfort in the back, shoulders, and neck, leading to pain, fatigue, headaches, and difficulty sleeping. There may also be issues with skin irritation beneath breasts.
On an emotional level, many women with exceptionally large breasts feel self-conscious in social settings. Quality of life issues are also a factor due to the fact that the weight of the breasts can interfere with exercising and recreational activities.
For men, gynecomastia, which describes an enlargement in the breast area due to localized fat and glandular tissue, is particularly embarrassing. Men are not “supposed” to have breasts but rather smooth tight chests. Most often, gynecomastia is caused by hormone levels that are out of balance and is temporary or treated by addressing the underlying condition. If this is unsuccessful and the individual experiences a significant level of embarrassment, breast reduction surgery may be the answer.
Breast Reduction: Medically Necessary or Cosmetic?
When it comes to breast augmentation surgery, unless it is reconstructive, such as following a mastectomy, the procedure is not considered medically necessary and, consequently, not covered by insurance. Whether breast reduction surgery is covered or not is a little harder to say.
Insurance companies recognize that macromastia, the technical term for having breasts that are out of proportion for body size, can create legitimate medical issues. While that is generally agreed on by most insurance companies, the hoops that must be jumped through to fulfill the requirements of proving that it is a true medical condition vary from company to company.
For most insurance companies, the physical symptoms of neck, back and should pain, headaches, skin rashes, and trouble sleeping must not only be present but documented. Requirements are likely to include multiple visits and reports from physical therapists, chiropractors, dermatologists or orthopedists. Some expect these visits and treatments to cover six months to a year. Absent this level of documentation, most companies will deem the procedure for cosmetic purposes and deny coverage.
Breast reduction surgery that is being done for emotional, appearance-related reasons is far less likely to be covered by insurance. This is unfortunate because the resulting self-esteem and confidence issues are very real and can be socially crippling. While the majority of insurance companies are not yet on board with the seriousness of the emotional aspects of macromastia, this is a developing opinion and those affected should always check to make sure exactly what their particular policy covers.
Breast reduction surgery, performed by an experienced and highly trained surgeon, can result in pain relief and improved appearance and self-image. Satisfaction levels with this procedure are consistently high.
Dr. Brian D. Cohen is a Board Certified Plastic Surgeon with extensive training in cosmetic/reconstructive plastic surgery and has had years of experience performing a wide array of cosmetic surgery procedures, specializing in procedures of the face, eyes, nose, breast and body and is known for his exemplary and compassionate care by his patients. Knowing that Dr. Cohen has been selected by his peers in Super Doctors for 6 years in a row in 2018 gives you the confidence that he is highly respected for his performance in his specialty.