One of the first questions women seeking a breast reduction surgery will ask is “Who will pay for breast reduction?” The good news is that these days, most insurance companies cover breast reduction surgery when it is deemed medically necessary. Since many of our patients come to Dr. Golshani with substantial physical complaints due to their breast size, most of these patients have been able to get insurance to cover their surgery costs. Dr. Golshani works with a experienced Insurance Specialist in Los Angeles who will help you understand the decision-making process, provide you with advice, and walk you through this step-by-step in order to maximize the chances of your insurance company paying for the surgery. Let’s cover a few things you should know about getting insurance coverage for surgery to reduce breast size.
Insurance policy exclusions
Cosmetic procedures that help to improve someone’s appearance and even procedures that insurance companies feel could be treated with nonsurgical methods are usually denied coverage. There are still a few insurers that believe that breast reduction is actually a cosmetic “breast lift” operation and that large breasts can be treated with weight loss. Thus, they may refuse coverage for women seeking this procedure. In addition, breast reduction surgery can sometimes be included on a health insurance policy’s list of coverage exclusions. Most commonly, this is seen in managed-care plans such as HMOs. However, in recent years, there has been increasing medical evidence that breast reduction surgery is a medical necessity and can help to improve the physical and psychological health of a woman. Insurance companies, even those excluding coverage of breast reduction, are beginning to take note.
Insurance coverage: process
It is common for health insurance companies to individually review cases and use established criteria in determining whether or not to cover a breast reduction surgery. Criteria commonly used to evaluate coverage include:
- Estimated weight of tissue to be removed from each breast, which often ranges from 300 to 800 grams per breast
- Bra cup size (Insurers usually require that breast reduction patients wear a C cup or larger)
- Patient’s percentile on the Schnur scale (Based on the patient’s body surface area and estimate weight of breast tissue to be surgically removed)
- Body weight and/or body mass index (BMI)
- Physical symptoms of large breasts including shoulder grooving, skin problems and deformity
- Other documentation of nonsurgical treatment(s) failure including weight loss, supportive bras, medications and physical therapy
Even if your insurance plan covers the surgery, you must meet their specific, written criteria and this can be a simple, straightforward process or a very difficult one. For example, for overweight patients, insurance companies may sometimes require significant weight loss to reduce body mass index below 30 before they authorize surgery. Therefore, weight loss or documentation of failed attempts of weight loss is often a significant requirement. In addition, insurers usually assign more value to specific criteria and symptoms.
How the insurance process works for reducing breast size surgery
Insurance companies require authorization before surgery, even if all criteria for coverage is met. Without prior authorization, they may not be obligated to pay for anything. To request this approval of coverage, our Insurance Specialists will write a letter to your insurance company detailing relevant medical information as well as an estimate of how much weight will be removed from each breast. Along with this formal request, photographs of your breasts taken during your consultation and insurance forms will be included in the preauthorization package.To expedite this process, it will be helpful if you bring the following documentation to your initial consultation:
- Current insurance card
- Valid driver's license or photo ID
- Pre-authorization or letter of referral from primary treating physician
- Evidence of previous conservative care such as weight loss or physical therapy
It may take several weeks for insurance companies to respond. If approved, it is important to get the approval in writing and to thoroughly understand what conditions have been placed on the coverage as well as your financial liabilities.
What to do if insurance denies your breast reduction surgery
There are several reasons an insurance company may deny coverage for a breast reduction surgery including policy exclusion and the lack of information provided to meet criteria. Health insurance denial can be frustrating but do not give up hope. Denials happens, and in this case, Dr. Golshani’s team will work with you to legally appeal the decision and help you to implement the following action plan:
- After studying the reasons for denial, file an appeal with the insurance company or in the case of policy exclusions, with your state department of insurance (some states even mandate breast reduction coverage for women who fit criteria).
- Provide more information which may include a detailed letter written by you describing your symptoms and physical limitations and supporting letters from other physicians or therapists.
- Wait...insurance companies usually respond four to six weeks after the appeal is filed.
Remember that it is your legal right to file an appeal and you should take full advantage of the appeal process. The more you are committed, the more there is a chance for success. Plenty of patients have successfully appealed a denial, and had their breast reduction paid for by insurance.
If we can answer any questions for you about insurance coverage, please contact us.