Will Insurance Pay for a Breast Reduction?

Tamsen Butler
Surgery

Will insurance pay for a breast reduction? The answer depends on whether or not the reduction is deemed medically necessary as well as the terms of the health insurance coverage.

Medical Necessity

Breast reduction surgery, which is referred to within the medical community as a reduction mammoplasty, is a procedure designed to decrease the size of breasts by removing non-vital tissue and, in some instances, excess skin.

Most insurance companies that cover the cost of this surgery will only do so if it is considered medically necessary. In many instances, there must be a valid medical diagnosis from an approved physician before the procedure will be considered medically necessary. Very large breasts can create discomfort in women, but this discomfort alone may not be sufficient to obtain approval from an insurance company for this surgery.

Medical Conditions Commonly Covered

A diagnosis of macramastia increases the odds of a breast reduction surgery being deemed medically necessary. This condition occurs when large breasts pull on the skin to the point of tearing or other damage. This can be quite painful and may occur during a short period of time. Other skin problems can occur with the skin underneath the breasts as a direct result of their weight. If these skin problems are perpetual and untreatable, breast reduction surgery may be approved by an insurance company.

Severe back pain or other severe and chronic body pain resulting directly from the size or shape of the breasts is generally considered a reason to regard breast reduction surgery medically necessary. This pain must be well-documented and affirmed by an approved physician. Nagging pain may not be sufficient to get an insurance company to agree to pay for breast reduction surgery; also, the insurer may insist upon more than one consultation from specialists.

Will insurance pay for a breast reduction when the problem stems from another medical procedure? For example, if a woman has a mastectomy or a lumpectomy and then wants to have reduction surgery to make the appearance of her breasts more symmetrical, will this be covered? If the procedure is needed as a direct result of another procedure covered by insurance, there is a good chance that the reduction will be covered, too.

Conditions Not Commonly Covered

Breast reduction surgery will probably not be covered by an insurance company if the discomfort may be the result of another medical condition. For example, if a woman has arthritis, it may be difficult to discern whether the arthritis causes the discomfort or if the pain is a direct result of the size of her breasts. Insurance companies are apprehensive to approve costly procedures for one condition when the procedure may not solve the underlying problem potentially caused by another condition.

Very large or asymmetrical breasts that do not necessarily cause medical problems, yet which cause emotional pain to the patient, may not be sufficient reasoning for the insurance company to cover the cost of the breast reduction surgery. Even if the patient consults with a psychotherapist who verifies that the shape or size of the patient's breasts cause severe mental duress, this may still not be enough to elicit approval from the insurance company. In these instances, insurance companies frequently deem the procedure as cosmetic.

Additionally, not many insurance companies will consider covering the cost of a breast reduction surgery for any patient under the age of 18 regardless of the reasons for the surgery.

When Will Insurance Pay for a Breast Reduction?

Patients who meet the insurance guidelines necessary to get approved for a breast reduction can expect to experience specialist consultations, lab tests, and photographs of their breasts that will be submitted to the insurance company for review. Once the procedure is approved, patients can work directly with a physician to schedule the breast reduction surgery.

Will Insurance Pay for a Breast Reduction?