Posted: April 10, 2015
Insurance companies don’t want to pay for things that are clearly medically necessary, let alone a procedure that may be partially cosmetic. Depending upon your insurance company, some do offer benefits for surgical treatment of symptomatic macromastia. Each policy has certain criteria that need to be met in consideration for payment for breast reduction. Typically, symptoms of back pain, neck and shoulder pain with failure of conservative management need to be ongoing and documented. In addition, they may have certain tissue requirements, for example, 500 grams of tissue needs to be removed for benefits. This may or may not be realistic, depending on the candidate.
Expect to pay for surgery, and do not expect financial reimbursement from your insurance company or you are likely to be disappointment and unprepared. Dr. Brown is not on any insurance plans and therefore does not take insurance for breast reduction surgery. However, in patients who undergo breast reduction surgery for medical reasons, she can provide you with documentation and codes for insurance billing purposes. Ultimately, it is your responsibility to obtain reimbursement from your insurance company. Never expect full payment back from your insurance, only a small percentage of overall cost is realistic. In patients who need to go the insurance route, it may be preferable to call your insurance company to determine if there are plastic surgeons who service your insurance plan, and then consult with the plastic surgeon your insurance recommends.
Here is one example of an insurance company’s policy for breast reduction reimbursement (every insurance company is different):
- The individual is at least 18 years of age or breast growth is complete.
- Macromastia is causing at least ONE of the following conditions/symptoms with documented failure of at least one continuous three-month trial of appropriate medical management:
- shoulder, upper back/neck pain, and/or ulnar nerve palsy for which no other etiology has been found on appropriate evaluation
- intertrigo, dermatitis, eczema, or hidradenitis at the inframammary fold
- The potential causes of the above conditions/symptoms, other than breast size (e.g., intervertebral disc disorder, arthritis and rheumatologic disorders) have been evaluated and ruled out OR breast size has been documented as exacerbating the underlying condition (e.g., intervertebral disc disorder, arthritis and rheumatologic disorders) contributing to symptoms.
- Preoperative photographs confirm the presence of BOTH of the following:
- significant breast hypertrophy
- shoulder grooving from bra straps and/or rashes need to be present
- Average weight of tissue to be removed in each breast is above the 22nd percentile on the Schnur Sliding Scale based on the individual’s body surface area (this is a sliding scale that specifies the amount of breast tissue that needs to be removed in grams, based on a patient’s height and weight).
Insurance does not cover reduction mammaplasty for either of the following indications because it is considered cosmetic in nature and not medically necessary:
- Surgery is being performed to treat psychological symptomatology or psychosocial complaints, in the absence of significant physical, objective signs.
- Surgery is being performed for the sole purpose of improving appearance.
Insurance does not cover suction lipectomy or ultrasonically-assisted suction lipectomy (liposuction) as a sole method of treatment for symptomatic macromastia because such treatment is considered unproven in the treatment of symptomatic macromastia.
In our practice, we do see insurance covering costs of prescription medications, preoperative testing and mammograms, and breast tissue pathology bills on a regular basis.