In the health insurance arena, there are procedures that are clearly medical, like an appendectomy, and others that are clearly cosmetic, like a facelift. Medical procedures, provided they are indicated and the patient meets criteria, are generally covered by insurance. Cosmetic procedures are considered non-medical, and they are usually not covered. Breast reduction surgery is tricky, in that it lies somewhere in the middle.
There is no question that breast reduction surgery has both medical and functional benefits. Patients with very large breasts have a host of mechanical problems, ranging from back and neck pain, to difficulty with exercise, and sometimes even difficulty breathing. Large breasts also usually mean skin on skin contact, where the low breast lies on the upper belly, creating a moist interface that can lead to rashes and other dermatologic problems. Beyond that, difficulty with exercise and hygiene can also lead to weight gain and psychological distress, although these are generally not on the list that insurance companies check.
In order to determine whether a breast reduction is medical rather than cosmetic in nature, most insurance companies want to know how much breast tissue will be removed during the surgery. There is a specific calculation for this, based on body surface area, which itself is based on a patient’s height and weight. If you are going to have enough removed, then you might meet criteria for the procedure to be covered. If your planned reduction is small, or the procedure is more of a lift than a reduction, you are probably looking at paying out of pocket instead.
But the insurance companies do not only consider amount of tissue to be removed. They also usually want to see an attempt at non-surgical intervention. This never made sense to me, as there are no other interventions that would make a breast smaller, or sit it higher on the chest wall. Some examples are physical therapy, chiropractic, or special undergarments (like $200 bras that feel like straightjackets). In some cases, the case manager might want to see that the patient met with a PT practitioner for over 2 years, or that multiple physicians have stated in writing that no other methods have worked. In still other cases, the insurance company might ask for proof of chronic rashes, so severe that they require IV antibiotics. The truth is that, until you start the claim, you will not actually know how reasonable or unreasonable the requirements will be in your case.
There is also the matter of whether the surgeon is in or out of network. For physicians who are in network, as long as criteria are met, the case may be covered. For out of network physicians, you must have out of network benefits with your plan. This, too, can sometimes be hard to determine. In most cases, the surgeon’s office should be able to determine pretty quickly if you have these options, and then you can start the authorization process.
It always amazes me when I hear things like the fact that penile implants are covered by Medicare, but women used to have trouble getting covered for breast reduction after mastectomy. The good news is that, even though the criteria could use a little work, in many cases breast reduction will be covered by insurance these days. These matters are on a case by case basis, and response times can vary from days to months. But if you do meet criteria, and you have a flexible plan, there is a very good chance that you can have your procedure covered by insurance with the doctor of your choice. It might take some work, but so do all things worthwhile.