When a procedure like breast reduction is judged medically necessary, it’s possible that insurance will pay for it. Some of the patients we meet here in North Texas are like this. However, having it covered isn’t always as simple as it appears. It is critical that you examine your insurance policy thoroughly. Policies differ significantly and can even alter from year to year.
If you think you could be eligible for insurance, review your policy carefully, go online, and even phone your insurer. Make sure you understand their requirements if they cover breast reductions.
Even before your initial appointment with a plastic surgeon, you may need to fill out documentation. Many insurance companies require documentation of failed non-surgical therapy for specific problems.
For example, pain relievers and muscle relaxants were provided but did not assist; prescription anti-fungal creams for rashes were ineffective; physical therapy or chiropractic care failed to reduce neck pain, and weight loss did not improve symptoms. Other physicians, such as your primary care provider, pain doctor, or ob-gyn, may also be able to submit letters stating that they believe you might benefit from breast reduction.
It’s possible that you’ll need to see an orthopaedic surgeon first, or that you’ll have to go through weeks of physical therapy.
If a particular quantity of breast tissue must be removed, you may only be eligible for coverage. The Schnur scale, which is based on a patient’s height and weight, is used. It’s just a chart that shows how much tissue must be removed (in relation to your height and weight) to be labelled a reduction rather than a lift.
Keep an eye out for policy exclusions when it comes to breast reductions. This implies that no matter what the reason, your insurance company will not fund breast reductions, even if your doctor feels it is medically required. It’s also worth noting that the combination of a large deductible and copayment restrictions can make paying outside of your insurance less expensive.
In my practice, I recently had a new patient consultation with a female college student about probable breast reduction surgery. This operation sometimes referred to as reduction mammaplasty, is used to relieve symptomatic macromastia (large breasts).
The weight of abnormally big breasts on the musculoskeletal system causes neck, shoulder, and back pain, which is a common symptom of macromastia. Breast discomfort and dermatitis or rashes beneath the breasts are examples of secondary symptoms.
Her doctor referred her to me, and she arrived with a prescription for a visit with a plastic surgeon because of her problem. The patient mistakenly believed that because she was referred to me by another physician, her health insurance plan would automatically cover the suggested procedure. She came in looking for a four-week wait for her breast reduction surgery over her winter vacation from college.
My team explained to her what would be required to gain insurance permission for her operation after conducting a patient history and regional breast examination.
This patient had no previous medical therapy or consultations for her macromastia, as it turned out. She had also never been recommended for physical therapy, chiropractic care, an orthopaedic consultation, or a dermatological examination.
This lack of treatment history may not be an issue for many treatments. The lack of history for this patient might be troublesome for breast reduction, which can be considered cosmetic or reconstructive depending on the patient — and the insurance company reviewer.
Unfortunately, the woman had not finished all of the requisite regimens for her insurance to pay for the reduction treatment.
After the prerequisites are met, she will be allowed to reapply for reduction mammoplasty coverage, but there is still no assurance that her insurance would cover the treatment. Naturally, as a college student, she couldn’t afford to pay for the treatment herself, and she was dismayed to learn about the insurance obstacles she’d have to jump through to get coverage.
This is just one example of why it’s critical for patients to do their homework before consulting a physician about their insurance coverage for any surgical treatment. The answer to the question “is breast reduction surgery covered by health insurance?” is difficult and depends on a number of factors.
Health insurance and breast reduction
Patients assume that if a surgery is classified as reconstructive, it is medically necessary and will be paid for by insurance. Many patients, on the other hand, believe that if an operation is considered aesthetic, it is neither medically needed nor covered.
Breast reduction, on the other hand, is often classified as a cosmetic procedure for insurance purposes until the patient can demonstrate a sufficient number of health difficulties and attempts to address those issues prior to undergoing corrective surgery.
Once the threshold is met, the insurance company may consider breast reduction to be a reconstructive treatment for that patient and pay for it. The issue is that each insurance company or insurance company reviewer may have a different threshold. Breast reduction surgery has long been regarded as a “hybrid” operation, in my perspective.
It is classified as reconstructive in order to qualify for insurance coverage, but it is also classified as cosmetic in the sense that consumers anticipate thorough aesthetic skill in their surgery and results.
In our clinic, obtaining insurance reimbursement for breast reduction surgery has become increasingly challenging. Before considering coverage, insurance companies often demand 2-3 written reports from other referred specialists. In addition, insurance companies frequently need proof and treatment from a physical therapist, chiropractor, dermatologist, or orthopedist for 6-12 months.
What does this entail for a patient who requires the operation due to macromastia-related chronic health issues? During this procedure, keep yourself up to speed on policies, as the insurance company’s criterion this year may not be the same as next year.
If you believe you are a candidate for breast reduction surgery and want your health insurance to cover it, you should contact your health insurance provider and request that they send you their coverage criteria in writing.
Each insurance business has its own set of criteria and indicators. While your next-door neighbour with a seemingly less serious problem may qualify for the operation through one insurance carrier, you may not receive the same response from yours.
To qualify for insurance coverage for breast reduction, it takes an average of 3-6 months of preparation, including secondary visits with other healthcare specialists and possibly therapy (physical therapy or chiropractic).
What are your plans for dealing with this? Any symptoms that may be related to your macromastia should be reported to your primary care physician as soon as possible. It’s never too soon to begin the process. Please contact your cosmetic surgeon’s office with any questions you may have about breast reduction surgery and insurance coverage, and they will do their best to guide you through the process so you can get the care you require.
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