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What Does Insurance Really Cover?


Getting your insurance company to cover breast reduction surgery much less anything these days can be quite challenging. While it is rarely easy to find insurance that covers a medical procedure that is not considered absolutely necessary or an emergency, breast reduction can and does qualify under certain conditions.

The first step in getting a breast reduction surgery approved by your insurance company is to find a plastic surgeon who has a good track record. Insurance companies are more likely to cover breast reduction surgery if it is performed by a reputable doctor known to them. Contact your insurance company to get a list of reputable plastic surgeons.

Schedule a consultation with a reputable surgeon. The prospective surgeon will perform a physical exam of your breasts and their effect on your body. If your surgeon determines that there are non-surgical alternatives that may reduce the symptoms caused by the size of your breast, you will have to attempt them before your insurance company will consider paying for surgery. Be aware that if your insurance company does not cover the breast reduction surgery you may be financially responsible for costs incurred during surgical consultations.

There are certain criteria that both the surgeon and patient must meet. The surgeon must be able to estimate and document that he or she can remove at least 500 grams (1/2 pound) from each breast. In addition, your surgeon must show that you have disabling symptoms directly attributable to your large breasts, and the surgeon must show that you have tried everything under your power to resolve the macromastia symptoms yourself. All of this documentation will be accompanied by photos. Only with all of this documentation is there a chance that your insurance company will pre-authorize the surgery.

Unfortunately, even with meeting the criteria, sometimes insurance companies want more. Most insurance companies now, in addition, require the woman requesting the surgery to be at or near her ideal weight. This often presents another problem because women with macromastia are often unable to exercise because their breasts are too big and cumbersome to manage exercising. Consequently, they are unable to lose the weight necessary to satisfy the insurance company’s additional requirements.

If your surgeon includes a letter regarding your prior history of macromastia during times of near ideal weight, this information will verify that if you were able to lose weight macromastia would still be an issue.

Contact your insurance company to find out exactly what documentation you or your surgeon will need to provide. This will vary from insurance company to insurance company. However, your surgeon will always have to show that the procedure is medically necessary.

Regardless, of how frustrating the insurance process may be it is critically important that both you and your surgeon only include honest information. Remember, if your insurance company does pay for the surgery you may still be responsible for a portion of the cost. Check your policy to be certain.
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Content copyright © 2013 by Denise M. Castille. All rights reserved.
This content was written by Denise M. Castille. If you wish to use this content in any manner, you need written permission. Contact Denise M. Castille for details.

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