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Getting Insurance Coverage for a Breast Reduction

By tmccall on July 10, 2014

A woman’s breasts being examined and measuredLarge breasts are often exemplified as a positive attribute, especially in the media, but breast size is a very nuanced matter. Body type and personal preference are important factors in what a woman may deem an ideal size. When breasts are relatively too large for the rest of a woman’s body or when they begin to affect her well-being, a breast reduction may provide a permanent improvement to her confidence and quality of life.

Because breast reduction is a form of plastic surgery, some patients may be initially skeptical of their ability to afford it. However, because a breast reduction also improves a patient’s long-term comfort and may alleviate potential health complications, the procedure is often more than just cosmetic. If you and your doctor are able to prove that the surgery is holistically beneficial to your health, there is an excellent chance that it can be partially or fully covered by your insurance company. If you are interested in a breast reduction, use the below guide as a reference for potential insurance coverage before visiting our Milwaukee clinic.  

Breast Reduction and Insurance Coverage

If you are seeking a breast reduction for purely cosmetic purposes, or you plan on having only a minor reduction in size, you may be out of luck. Insurance companies are reluctant to cover any procedures they deem elective, or those that have no bearing on your health. However, if you and your doctor can prove that the procedure will improve your overall health, both immediately and in the long run, then there is a good chance you can gain coverage. In such cases, your plastic surgeon would recommend that you have the procedure for the aforementioned reasons, and the insurance company would verify it with a team of their own professionals. Fortunately, most women who seek a breast reduction do so for reasons of comfort and health in addition to aesthetics, making them good candidates for coverage.

Conditions for Coverage

If you are considering a breast reduction, it is a good idea to contact your insurance company in order to find out their typical conditions for coverage. Most companies require multiple types of proof that the reduction will have substantial impact on your body and your well-being. In most cases, this proof will come from your surgeon, which will be further reviewed by doctors in the employ of the insurance company. While standards may different among companies, common criteria for coverage include:

  • Weight of tissue removed: The company will consider how much tissue is being removed from each breast. This is assessed in conjunction with your body surface area (BSA). For the average patient, this requires around 500+ grams of tissue to be removed. 
  • Body surface area: Your BSA is a calculation resulting from your height and weight, which indicates how much surface area your body comprises. This helps insurers gain a clearer idea of your breast size in relation to the rest of your body.
  • Persistent symptoms: You must indicate that you’ve had multiple problems resulting from your breast size, and that these problems are consistent. Back pain, shoulder pain, and discomfort from bra straps are typical indications in this area.
  • Alternative treatments sought: Insurance companies don’t like to cover breast reduction surgery unless it is deemed a necessary solution. They may therefore require that you attempt non-surgical treatment methods first, such as physical therapy, specialized bras, and analgesic drugs.

For each of these conditions, your surgeon will most likely need to sign off on the appropriate documentation and provide photographic evidence of your body’s proportions. Although these steps may seem meticulous, the end result is often a huge financial boon for patients.      

Take the First Step toward Getting Insured

The best way to estimate whether you are eligible for coverage is to meet with your plastic surgeon. By scheduling a consultation and exam with Dr. McCall, you can gain a better idea of what the procedure will entail, and whether this will be a significant enough change for insurance coverage. Moreover, you can discuss your goals for surgery and any additional steps that need to be taken before coverage is likely. Even if you are not eligible for insurance coverage, our staff will be ready to assist you with financing options and ways to reduce your up-front expenses.  

Schedule Your Exam

Visit our office to speak with Dr. McCall and, if you’re ready to begin the process, begin documenting the necessary information for your insurance company. Contact us to schedule your initial consultation or exam.

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