Breast reduction cosmetic surgery (reduction mammaplasty) is sometimes performed to alleviate or improve medical symptoms of pain and discomfort caused by oversized breasts. However, there is no guarantee that insurance will cover the costs of breast reduction in every case.
Every health insurance provider may have a different opinion on what comprises a “medical necessity.” The basic minimum requirement to qualify for insurance coverage in case of breast reduction surgery is medical necessity. But the insurer could still refuse to provide coverage, depending on their evaluation of the patient’s medical documentation.
Additionally, the insurance providers may change their minimum requirements from one plan year to another. Considering these aspects, it is important to obtain advance approval from the insurance company, especially when a patient is counting on her insurance to finance the breast reduction procedure.
Dedicated board certified plastic surgeon Dr. Jacob Bloom provides breast reduction to patients in Chicago, IL and surrounding locations.
How to Use Medical Insurance for Your Breast Reduction Surgery
Here are some suggestions to help you receive insurance coverage and understand the details of your coverage comprehensively:
- Go through your health insurance coverage materials or review the insurance provider’s website for your specific level and type of medical insurance coverage. Understand if they may cover breast reduction surgery to address the symptoms that you experience. However, never rely on your own comprehension of the insurance firm’s rules. Reviewing the written material may help you understand something regarding the conditions under which your surgery may be covered or coverage request process.
- After that, call the insurance provider to see whether you need pre-approval for a breast reduction and lift procedure.
- Get information on the documentation that your insurer needs from the physician to determine medical necessity. Procuring documentation from your surgeon and physician will possibly be the most convincing.
- If the insurance company believes that your oversized breasts are leading to symptoms (back pain, shoulder pain, infection, or skin rashes, etc.) that will need continuous, costly treatment (that they will need to cover), then they are more likely to provide full or partial coverage for your breast reduction surgery. However, there is no guarantee that the insurer will offer coverage due to this logic.
- Understand whether the insurance provider needs a second surgical or medical opinion prior to offering approval for your breast reduction surgery and lift. Determine if they will select the physician for your second opinion.
- If the company places a network restriction limiting the choice of surgeons, you will need to determine if you will be able to use the aesthetic surgeon of your choice (if it is acceptable to you to reduce reliance on insurance coverage for the surgery). Some insurance companies allow out-of-network surgery at lesser coverage, while other insurers do not allow out-of-network procedures unless it is an emergency situation.
Other Factors to Consider
Check with your insurer if they will provide coverage for anesthesia and other expenses for the breast reduction surgery. If your insurance provider does not provide coverage for what you believe they agreed to pay for as per your insurance plan, you can review grievance procedures, ask them to reassess their decision on coverage or reprocess bills.
Many insurance companies have a process for grievances which may be worthwhile to explore. Cordial cosmetic surgeon Dr. Jacob Bloom receives patients from Chicago, IL and suburbs and neighborhoods in this region of the Midwest for breast reduction.
Successful and focused cosmetic surgeon Dr. Jacob Bloom receives patients from Chicago, IL, and other suburbs and cities in this part of the center of the country for a breast lift.