Patients assume that if a surgery is classified as reconstructive, it is medically necessary and will be paid by insurance. Many patients, on the other hand, believe that if an operation is considered aesthetic, it is neither medically needed or 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 of 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 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 neighbor 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 chiropractics).
How can I get my insurance to cover a breast reduction?
Large breasts (macromastia) can produce physical problems that interfere with a woman’s daily functioning, as I discussed in my earlier post. Symptomatic macromastia is a well-known medical disorder that requires treatment. Insurance coverage of reduction mammaplasty is just as suitable as coverage of cervical spine surgery, shoulder surgery, carpal tunnel release, or sleep apnea treatment because big breasts put constant strain on body systems. Non-surgical treatments should be attempted initially for some disorders, but there are no non-operative treatments for macromastia that are expected to provide long-term or permanent symptom alleviation.
If you’re thinking about having breast reduction surgery, make sure you read your insurance coverage first. If your insurer specifies reduction mammaplasty as a policy exclusion, you might not even be able to get coverage for a consultation to see if surgery is right for your symptoms.
In most situations, insurers demand that the surgeon produce a statement outlining the patient’s symptoms and physical results, as well as an estimate of the breast weight to be removed and a request for coverage. This should be done before scheduling surgery since if surgery is not preauthorized, the insurer may refuse to pay. If your insurer refuses to pay breast reduction surgery because it is considered cosmetic, your doctor must inform the insurer about symptomatic macromastia and the differences between breast reduction and its aesthetic cousin, the breast lift. Traditional Medicare and Medicaid plans may not offer preauthorization.
Current insurers should be aware of the current standard of care for treating macromastia and should accept coverage based on reasonable criteria and medical necessity verification. Unfortunately, too many insurance companies have yet to study the medical research from the last two decades demonstrating the usefulness of breast reduction surgery in alleviating macromastia symptoms independent of a woman’s body weight. Many of these businesses employ a chart based on the Schnur Scale of 1991, which correlated a woman’s reasons for breast reduction with her body weight. Because of their position on the chart, many women are denied coverage. The use of such a chart to discriminate against overweight women by refusing them coverage regardless of their symptoms has no medical validity, according to recent medical research, but insurers continue to do so.
Your doctor’s report of your symptoms and physical changes caused by your breast weight should be utilized to determine medical necessity. Even though non-surgical therapy trials have a low chance of success, they may be required before surgery is covered by insurance. Although it is reasonable for an insurer to require that a certain amount of breast tissue be removed, there should be a mechanism in place to ensure that special circumstances (such as a small-framed woman or a woman with a medical condition made worse by even moderate breast weight) are given special consideration.
You have the legal right to appeal a denial if you believe breast reduction is important for your health and well-being. The denial letter should include information about the appeals process. Multiple levels of appeal are available in most circumstances, and you should take use of them. A family doctor’s letter, an orthopedist’s letter, a physical therapist’s letter, a chiropractor’s letter, or a massage therapist’s letter can all help support an appeal. You should create your own letter in which you describe your symptoms and how they have hampered your life (focus on your physical problems rather than your difficulty finding a bathing suit). Request that your doctor attach your personal letter, supporting letters, current scientific information on the standard of treatment for treating symptomatic macromastia, and a list of medical literature references to your appeal.
What qualifies you for breast reduction?
Breasts that are too big might create health and emotional issues. You may also endure physical pain and discomfort in addition to self-image concerns. Excess breast tissue can make it difficult to maintain an active lifestyle. Emotional distress and self-consciousness are frequently associated with large pendulous breasts, and they can be just as problematic as the physical discomfort and agony.
The weight of your breasts causes pain in your back, neck, and shoulders.
How much does DD cup breast weigh?
For both of your breasts, DD cups can weigh up to 4.2 pounds. Each of your breasts may weigh around 950 ml or 2.09 pounds if your bra size is a DD cup. Your bra size can also help you estimate how much they weigh.
How much is a breast reduction 2020?
According to 2020 figures from the American Society of Plastic Surgeons, the average cost of a breast reduction (for cosmetic purposes solely) is $5,913. This is only a portion of the entire cost; it excludes anesthesia, operating room facilities, and other related costs.
Does a breast reduction include a lift?
A breast lift is not included in breast reduction surgery. A breast lift is included in all breast reduction operations. After the extra tissue is removed in a standard breast reduction, the nipple is lifted to a more suitable position as part of the redraping process.
How much is a breast reduction out of pocket?
- A breast reduction normally costs between $5,000 and $7,000. According to The American Society for Aesthetic Plastic Surgery, this estimate includes anesthesia fees of $1,000 to $1,500 and facility fees of $500 to $2,000, as well as the surgeon’s fee, which averages $5,500. Very big breasts that require more tissue removal and reshaping of the nipple area might expect to pay more. As a result, a doctor will need to conduct an in-office consultation in order to provide an exact cost estimate.
- The surgeon makes incisions in the breast, usually around the areola and beneath the breast, and then removes excess fat and tissue to achieve the desired size. Because the weight of huge breasts can stretch the areola, the doctor would usually lower the size of the areola, then remove superfluous skin and lift the breast to make it higher and firmer. The surgeon frequently leaves the nipple attached during surgery to preserve nipple feeling and the ability to breastfeed.
- Breast reduction treatments are described and illustrated by the American Society for Aesthetic Plastic Surgery.
- Post-surgical support bras, which typically cost over $100 each, and a hot/cold breast compress, which costs around $25. Doctors will also prescribe pain medicine, which may or may not be reimbursed by insurance.
- Additional surgery may be required in some cases, either due to problems or because the patient is unhappy with the results. This can be just as expensive as, if not more expensive than, the first treatment.
- Ask your surgeon if permitting your before and after images to be used on websites or in commercials will get you free or discounted treatments.
- Health insurance will often cover the cost of breast reduction because it is not necessarily considered a cosmetic procedure and can help with health issues including back discomfort and posture issues. Consult your insurance company as well as your doctor, who may be required to submit a letter saying that the reduction is medically necessary.
- Look for a board-certified plastic surgeon who has a lot of experience with breast surgery. A free recommendation service is provided by the American Society of Plastic Surgeons. Discuss the benefits as well as the hazards with your surgeon, which include infection, numbness or a change in nipple sensation, and even loss of circulation to the nipple, which may necessitate nipple removal. Smokers are more likely to lose their nipples, therefore they should stop smoking at least two weeks before surgery.
Is breast reduction surgery painful?
It’s common to feel some pain and discomfort in the days following your surgery. It’s possible that your breasts and the areas around them will be bruised and swollen. This is due to the stretching of the breast tissues and muscles.
The first few days after surgery are the most painful for most women. Your doctor may prescribe pain relievers if necessary to alleviate the discomfort.
Additionally, drainage tubes may be inserted on your breasts as part of the recuperation procedure to help reduce swelling. These are frequently removed after a few days of surgery.
Women recovering after breast reduction should wear specific surgical bras to protect the tissue during this time, according to medical specialists. Finally, during this time, it’s critical to avoid overly strenuous activity.