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Does Insurance Cover Breast Reduction Surgery

What Are The Out

Breast Reduction Surgery and Health Insurance Coverage (Q& A)

The costs youll pay for your breast reduction depend on the type of Medicare plan you have and the facility where you have your surgery. Youll be covered no matter which plan you have, as long as your reduction is medically necessary.

Medicare Advantage plans are required to cover everything that Medicare parts A and B cover. However, the cost youll pay might be different from plan to plan.

Maturity And Responsibility Are Key

Ensuring the best possible results means that the young male patient needs to follow his surgeons instructions closely.

For instance, your surgeon may require you to wear a compression garment over your chest after the surgery for two weeks. Some younger patients may think this is bothersome, but its vital to keep the garment on to protect the incisions and reduce swelling.

Also, the patient needs to take a break from sports and other physical activities thats why many teenagers opt to have their procedure over the holidays.

You Need Imaging Or Exams To Prove The Diagnosis

Addressing your breast implants might not be as simple as just scheduling an appointment with the plastic surgeon who did the breast augmentation. Depending on the patients insurance, they may see an OB-GYN, a general surgeon, or a primary doctor first, says Dr. Karanetz. The next step would be seeing a specialist, such as a plastic surgeon, getting evaluated and undergoing a physical exam, to see if there is anything wrong with implants.

If your surgeon does suspect a complication, they may send you to get imaging. While you need only a physical exam for diagnosis of capsular contracturefor which photos will usually sufficerupture requires diagnostic imaging. That can cause some issues with insurers. The insurance company will not necessarily pay for the MRI, and the MRI can cost a couple thousand dollars, says Diana Zuckerman, president of the National Center for Health Research, a nonprofit that helps consumers navigate their explant options. So thats a bit of a catch-22.

In some cases, you may need to do an ultrasound first, since these tend to be less expensive for insurers than MRIs. The most sensitive and specific diagnostic imaging tool is MRI, says Dr. Karanetz. Sometimes you have to jump through hoops and get approvals and authorizations to get the MRI donebut its the gold standard.

Interested in breast implant removal?

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Cosmetic Surgeries That Are Covered By Insurance In Canada

If youve been thinking about going under the knife and getting some work done but are concerned about cost, you might be happily surprised to learn that your health insurance might kick in some of the cost for some procedures. Thats right, cosmetic surgery might not be out of the realm of possibility for you.

Documentation From Your Plastic Surgeon


In addition to requiring documentation of non-surgical treatment attempts, your insurance company may require documentation from your plastic surgeon. This may include measurements, estimates of the amount of breast tissue that will be removed, and more. It is important that you know what exactly your insurance provider will require and that you maintain communication with them throughout the process. We are happy to provide this documentation as requested.

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When Is Breast Reduction Medically Necessary

If your plan covers breast reduction surgery, you must meet Cigna’s breast reduction eligibility guidelines to receive coverage. To qualify, your surgery must be medically necessary. You must also be at least 18 years old at the time of surgery, or your breasts must have finished growing.

Cigna considers breast reduction surgery medically necessary to treat macromastia, a condition where the breasts are disproportionately large. Cigna only covers treatment if macromastia causes one of the following conditions and your symptoms don’t respond to conservative treatment:

  • Skin conditions, such as eczema or intertrigo around the breasts
  • Ulnar nerve palsy with no other medical cause
  • Shoulder, upper back or neck pain

Furthermore, Cigna evaluates the amount of breast tissue requiring removal to determine whether a breast reduction is medically necessary. You may be eligible for coverage if the amount of breast tissue your surgeon plans to remove exceeds the 22nd percentile on the Schnur chart. This chart compares the quantity of removed breast tissue to your body surface area. Alternatively, you may qualify if your surgeon intends to remove over 1 kilogram of tissue per breast, even if you don’t meet the Schnur chart requirements.

How Long Does Breast Reduction Surgery Take

In general, the surgery takes about three to four hours. Removing excess breast volume , creating an aesthetic contour and closing the wound to minimize scarring can take additional time in some patients.

Patients with extremely large breasts may require more complex surgery. The surgeon may remove the areola and nipple before making the breast smaller, and reattach them after the breast is reduced.

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Discuss With The Insurer

Leading insurers should be updated about the current standards of care to treat macromastia, and should approve coverage according to the documentation of medical necessity and other reasonable conditions. However, several insurers continue to ignore the last two decades of medical research literature demonstrating the benefits of breast reduction surgery in treating symptoms of macroastia, irrespective of a womans body weight.

If the insurance company denies coverage by terming breast reduction as an elective procedure, the surgeon may try to educate the insurer about symptomatic macromastia. The difference between breast reduction and its cosmetic cousin breast lift should be made clear. Appropriate medical evidence of the patients persistent pain and discomfort should be provided.

Once the insurer is convinced that ignoring treatment for painful macromastia may later on cause more physical complications, they may be ready to provide coverage for breast reduction. It can save costs in the long run for the insurance company.

Does Insurance Cover Breast Reduction

Will insurance cover breast reduction surgery?

For many women, breast reduction surgery offers a chance to bring their bodies into proportion and provides both physical and mental comfort. But how does one pay for such a procedure? Is this the kind of surgery that insurance companies will pay for? In this post, Dr. Ary Krau discusses whether insurance companies will cover breast reduction surgery and offers insight into how patients have financed their procedures in the past. Read on to learn more.

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What Are The General Breast Reduction Insurance Requirements

Most insurance carriers will offer breast reduction covered by insurance as long as it meets certain requirements to be deemed “medically necessary”. Traditionally the main point an insurance company considers 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 relative to a patient’s height and weight. However, these days insurance companies are beginning to focus more and more on patient’s symptoms in order to determine whether breast reduction is medically necessary. Health concerns such as back and neck pain, or skin rash developing in the skin underneath one’s breasts may be sufficient to qualify a patient for insurance coverage for breast reduction. Typically any procedure in which the breasts are reduced by less than two cup sizes is categorized as a breast lift and will not be covered by insurance.

Getting An Insurance That Covers Breast Reduction Surgery

Although the process may vary according to the insurance company, breast reconstruction will be covered by most insurance plans. Patients who are interested in having their surgery performed must provide their insurer with a letter of medical necessity. This states that the procedure is necessary to treat an underlying condition. To ensure that other treatments are not excluded, most insurance companies will require 6-12 months of documentation.

Requesting a letter from your insurance company detailing the requirements for approval is the best way to speedily get approval. This is done well before you have any breast reconstruction surgery. Because each insurance company has its own approval criteria, this is crucial. The average turnaround time after submitting all necessary documentation can take anywhere from 3 to 6 months.

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The insurance provider can confer with the treating doctor and seek second opinions from other healthcare providers, such as chiropractors, to confirm that the surgery is medically necessary. It is best to notify your doctor that you intend to have the procedure covered by insurance. This helps ensure that letters of medical necessity are sent promptly to your insurance provider.

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Results May Or May Not Be Permanent

Having male breast reduction surgery before puberty comes with a risk that the results may not be permanent. Hormone levels in the body are still changing, so its possible that the condition can return.

Also, medication use and weight changes in the future can cause the breasts to enlarge again. Thats why many surgeons encourage patients to wait until they are after 18 to have the surgery. That is when they are most likely to be done with puberty and no longer need parental permission for the operation.

However, if the enlarged male breasts are causing emotional and social problems, it may be beneficial to have the surgery earlier than later, even if the condition could recur.

Does Blue Cross Blue Shield Cover Breast Reduction Surgery

Pin on How to get breast reduction surgery covered by insurance
  • Blue Cross Blue Shield healthcare plans may cover breast reduction surgery. Find out who qualifies for Blue Cross Blue Shield breast reduction coverage.

Roughly a third of Americans have healthcare insurance through a Blue Cross Blue Shield company. If you need a breast reduction for medical or cosmetic reasons, you may be wondering if your Blue Cross Blue Shield plan will cover the costs of your surgery.

Breast reduction surgery is sometimes called reduction mammoplasty. It involves removing tissue from the breasts, and some private insurers include it as a covered benefit in certain circumstances. Below, you can learn about the Blue Cross Blue Shield breast reduction eligibility requirements.

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Is Breast Reduction Right For Me

You may be considering reduction mammoplasty if you wish to change your appearance or if you have large breasts that are causing or contributing to:

  • Neck strain
  • Low back pain
  • Chronic skin infections under the breast fold

Whether you wish to relieve discomfort or have your breasts reshaped for an appearance more pleasing to you, breast reduction can help.

Does Breast Reduction Surgery Affect Sensation In The Breast

Sensation loss is a real concern, Manahan admits. Its hard to guarantee breast and nipple sensation will be the same after breast reduction. As surgeons, we do everything we can.

There is not one major nerve that we can see and preserve when we operate. The nerves that supply sensation are more like seedlings or sprouts in a pot, and sometimes removing excess tissue from the interior of the breast results in areas of numbness. If loss of sensation is a serious concern for the prospective patient, thats an important factor to consider.

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Will Insurance Cover My Breast Reduction

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Breast reduction is one of the most popular procedures that plastic surgeons do, and typically breast reduction patients are very happy with their results. It is one of the few plastic surgery procedures that is covered by insurance. However, patients must meet a number of criteria before their insurance will pay for this surgery.


The medical indications for breast reduction include chronic back, neck and shoulder pain as well as intertrigo, or yeast infection, caused by large breast size. Typically, a patient needs to have these problems documented by their primary care physician over a period of time, as well as attempts to treat these problems without surgery, such as anti-inflammatory medications, physical therapy, and anti fungal treatments. Only after patients have tried other treatments and continue to have problems will insurance consider coverage.

In addition, most insurance companies have a scale that requires a certain weight of breast tissue to be removed relative to the patients overall height and weight.

What Are The Blue Cross Blue Shield Breast Reduction Eligibility Requirements

HUGE Breast Reduction Lift Surgery | Complications, Insurance Coverage, Pre-OP Medical Clearance

Eligibility requirements for breast reduction surgery vary across policies and providers. Generally, you must be 18 or older to be eligible. However, Blue Cross Blue Shield may cover enrollees younger than 18 whose breasts have finished growing if they have consent from their parent or legal guardian.

Often, you’ll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Alternatively, you may qualify if your breast size causes significant symptoms, such as:

  • Long-term neck, shoulder or neck pain
  • Grooving where the bra straps sit on the shoulder
  • Persistent skin irritation around the breasts

Blue Cross Blue Shield may require you to try conservative treatment options like anti-inflammatory medications, supportive garments or physical therapy before approving coverage.

All healthcare insurance policies that include medically necessary mastectomy are legally required to also cover reconstructive breast surgeries, per the Women’s Health and Cancer Rights Act of 1998. However, there is no legal requirement for healthcare insurance plans to cover mastectomies. You’ll likely be eligible for Blue Cross Blue Shield breast reduction coverage if your policy covered your mastectomy and you require surgery to make your breasts symmetrical. However, the company does not cover reconstructive surgery if you had a mastectomy for reasons not deemed medically necessary.

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Breast Reduction Surgery: Recovery

Pain medication may be prescribed for immediately after the surgery.

Patients should plan on taking weeks off work. Manahan recommends, During the recovery period, you want to be careful and protect the chest and avoid strenuous activity.

Swelling and minor bruising are normal, and these signs will generally calm down over a few weeks. Your surgeon may recommend that you wear an elastic pressure garment for additional support and protection during your recovery.

Patients, in general, are very happy afterward, says Manahan.

Rising Rates Of Insurance Denial For Breast Reduction Surgery

  • Wednesday, July 29, 2020

Breast reduction surgery is the standard of care for women with physical and psychological symptoms caused by overlarge breasts . In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018 but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure.

“The rate of pre-authorization denials for reduction mammaplasty is high and has been steadily increasing,” comments senior author Linda G. Phillips, MD, of University of Texas Medical Branch, Galveston. “Plastic surgeons are now required to have deep knowledge of insurance policies for delivery of high-quality care.”

The researchers analyzed their hospital’s experience with insurance preauthorization for reduction mammaplasty in 295 patients from 2012 to 2017. Trends in approval or denial of insurance coverage were analyzed, including reasons for denial and differences between insurance companies. The study appears in the August issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons .

Twelve percent of cases were denied because the weight of the predicted or actual breast tissue to be removed was “less than the minimum acceptable resection rate.”

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Tamoxifen In The Treatment Of Idiopathic Gynecomastia

Kasielska-Trojan and associates analyzed digit ratio in relation to estrogen receptor and progesterone receptor expression and verified digit ratio as a marker of ER and PR over-expression in the male breast. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. The average age of the studied individuals was 25.7 years ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. ER expression did not correlate with the right and left 2D: 4D . Also, there was no correlation between PR expression and 2D: 4D. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects . The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio.

Discuss Your Breast Reduction With A Plastic Surgeon In Nj

Does Insurance Cover Breast Reduction

The first step in the breast reduction process is to meet with a breast reduction surgeon in NJ to discuss the surgery. You will be able to learn about the surgery, if youre a great fit and what the next steps are.

Our Aesthetic and Reconstructive Surgeons are dedicated to your health and well-being. We are available to answer your questions and determine if youre a good candidate for surgery.

If you are working with a dedicated breast specialist and plastic surgeon in NJ, he or she will typically be happy to provide required information to your health insurance company, with your permission, that may help them determine coverage for your breast reduction and lift. Your insurer may also require information from your primary doctor. Schedule a consultation with one of our expert surgeons at Cohen Winters to learn more about your breast reduction options.

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