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Breast Reductions & Insurance Coverage

Breast Reductions & Insurance Coverage

Many people fail to realize the day to day struggles that women with large breasts face. Large breasts can cause physical problems that can interfere with a woman’s daily functions. Overtime this can lead to surgeries like cervical spine surgery, shoulder surgery, carpel tunnel release or sleep apnea treatment. If your breasts cause pain and alter your daily routine, it might be time to think about getting breast reduction surgery.

If you are hoping your insurance company to cover it, the first thing you need to do is read your insurance policy. Make sure that you are reading a completely updated version, most insurance companies change their terms and conditions annually, it is important to make sure you are reading the right information. If your insurance provider lists reduction mammoplasty as policy exclusion, you may not even get coverage for a consultation to discuss whether surgery is appropriate for your symptoms or not.

In most cases, insurers require the surgeon write a letter describing the patient’s symptoms and physical findings, estimating the breast weight to be removed and ultimately requesting the coverage. Typically, the main point insurance companies consider is the amount of tissue to be removed from each breast. Most major insurance companies have established basic criteria as to the amount of tissue that must be removed in accordance with the patient’s height and weight. However, recently insurance companies have been focusing more on a patient’s symptoms in order to determine whether breast reduction is medically necessary. Health concerns such as frequent or long term back and neck pain may be sufficient to qualify a patient for insurance coverage. Typically any procedure in which the breasts are reduced by less than two cups sizes is categorized as a breast lift and will not be covered by insurance.

If you are denied by your insurance provider but feel that the surgery is necessary for your health and well-being, you are legally entitled to appeal. The appeals process will be provided in the denial letter. Letters from a family doctor, orthopedist, physical therapist, chiropractor or massage therapist can help support your appeal. You should also write a detailed explanation of how you feel, describing your symptoms and physical pain. Providing as much up to date medical information can increase your chances of getting covered.

The terms and guidelines that are used to determine your breast reduction medically necessary may vary depending on insurance company, the state you live in and your specific policy. It will differ for every company and person’s specific situation. If you have any questions, please feel free to call our office to discuss the options or schedule your consultation!