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Breast Surgery: Can Insurance Cover it?


From breast reduction to post-mastectomy breast reconstruction.


We typically refer to out-of-pocket costs when discussing about cosmetic surgery, as such services are considered elective and not medically necessary. On the contrary, health insurance coverage may be relevant when discussing the reconstructive aspect of the services . According to the American Medical Association (AMA), cosmetic and reconstructive surgery can be defined as follows.


Cosmetic Surgery: Performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.


Reconstructive Surgery: Performed on abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.


If you picked this article, you are probably thinking about getting some kind of Breast surgery. So, what does the difference between "cosmetic" and "reconstructive" mean to you? If you want to get a bigger cup size, you'll probably have to pay for breast augmentation. But there are reasons breast implants and other ways to make a woman look better could be considered "reconstructive." Also, reducing the size of the breasts is one of the most common procedures that Insurance may cover. To help you determine if your insurance will pay for breast surgery, we will break down some of the most important things you need to know.


Why Breast Surgery May Be Covered by Insurance

There are no sure things when it comes to insurance coverage. No one knows what will qualify because no rules say. It is entirely up to the insurance company to decide. Still, there are some situations in which, with the proper paperwork, a procedure may be covered.


A. Post-Mastectomy Breast Reconstruction

Reconstruction can be done differently, depending on the patient's body and what they want to look like. Breast implants are one option. Whether you have one breast removed or both, your insurance company must pay for reconstruction for both breasts. In these situations, surgeons don't have to keep track of symptoms or tries of other treatments.


B. Shoulder, Neck, & Back Pain

Anyone with back, neck, or shoulder pain knows how hard it can be to move around. It can be hard to treat whether the pain is caused by an injury, bad posture, or the size of the breasts. This is especially true if the pain comes from having a big chest. Researchers have found a link between having large breasts and having back pain that lasts for a long time. This may be because the weight of the breasts causes the spine to curve a certain way. Because of this, insurance companies might pay for a breast reduction to improve the quality of life.


C. Difficulty In Preforming Physical Exercises

Working out is complicated enough on its own, but some women with big breasts find it even harder. When you move, your breasts move with you, which can be very painful during high-intensity or even low-intensity workouts. It may not be possible to find sports bras that are supportive and hold enough, and some women even wear two at once. Some women with big breasts can't work out and get the health benefits of it. This can help show that breast reduction is medically necessary.


D. Rashes

If you have rashes under your breasts that don't go away, your insurance company might pay for a reduction surgery. Large breasts often hang down and cover other parts of the chest. This can cause friction between the skin and/or make it hard for sweat to dry. Usually, sweat from the crease between the breasts evaporates on its own, but the damp environment can cause irritation and rashes for women with larger breasts.


E. Bra Strap Grooves

When you take off your bra at the end of the day, do you ever see marks on your shoulders? It usually means that the underwear is too tight or too heavy. Most people only have to deal with this occasionally, but some women with bigger breasts have permanent grooves in their bra straps because their breasts are too heavy to be adequately supported. Even though these marks might not be enough to get a discount on their own, they can be used as supporting evidence when making a case.


F. Headaches

Can having large breasts give you a headache? Research shows that the answer is yes. Studies have found a link between chronic headaches and large breasts, and women who had headaches or migraines before breast reduction said they felt better after the surgery. It's not clear what the exact link is between the two, but it's thought that the weight of the breasts can stress the muscles in the head, just like it can on the muscles in the back, neck, and shoulders.


How to Build a Case for Insurance

So, how do you get your breast surgery paid for by Insurance? The truth is that it's going to take time and patience. Aside from people who need breast reconstruction after a mastectomy, you must show proof to your insurance company and get preauthorization before proceeding. Insurance companies are not going to pay for breast surgery for just anyone. In the case of reduction mammaplasty, also known as breast reduction, you need proof of why you need the procedure. Some or all of the following are examples:


Photography: Standardized photography of the breasts taken by a medical professional is usually required to visualize the breast hypertrophy or overgrowth of breast tissue.


Symptoms: Chronic symptoms, like many of those listed above, must be experienced for at least six months (though usually a year or more) before building a case.


Alternative Treatment: Proof of unsuccessful non-surgical treatments, including visits to a physiotherapist, supervised weight loss, or the inability for rashes or other skin conditions to be cleared up by a dermatologist, must be submitted.


Surgical Plan: Based on your weight and height, your certified plastic surgeon must tell you how much tissue they plan to remove from each breast. A reduction must be a certain amount to be considered medically necessary by an insurance company.


Surgeon's Statement: Additionally, your medical team will need to share their opinion on why your symptoms are best treated with breast reduction surgery.

Neck pain, back pain, bra strap grooves, headaches, rashes under the breast, and not being able to exercise are all excellent reasons to think about breast reduction surgery, but that doesn't mean that Insurance will cover it. They can still be turned down. And insurance companies often want proof of physical therapy and occupational therapy to keep people from having surgery. You can't just build a case for preauthorization on your own. Your primary care doctor, specialists in physical or occupational therapy, and a certified plastic and reconstructive surgeon will all be involved.


NEXT STEPS

If your case for a breast reduction is approved, your insurance will pay for the surgery, but there will be some rules. You will need a report that shows the procedure was done according to the plan that was approved ahead of time. That means getting the required amount of tissue taken out by an in-network surgeon at an approved facility, which is usually a hospital.


The Take-home message

There are no "sure things" in Insurance, but you can take steps to increase your chances of getting coverage. Along with keeping good records, one of the best things a potential patient can do is work with a certified plastic surgeon who is an expert in the procedure they want. They probably have a lot of experience with the preauthorization process, and they should also know how to give you the best medical and cosmetic results for your body and goals.



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