How to Get Health Insurance Coverage For Breast Reduction Surgery

Insurance Coverage for Breast Reduction 

Breast reduction surgery, or reduction mammoplasty, can provide relief for individuals suffering from physical discomfort due to large breasts. While many people pursue this surgery for medical reasons, getting insurance to cover the procedure requires demonstrating its necessity. Here’s a step-by-step guide to help you navigate the insurance process and improve your chances of approval.

1. Understand Your Insurance Policy

Before pursuing breast reduction surgery, review your insurance policy to determine if the procedure is covered. Many insurance providers classify it as a medically necessary procedure under specific conditions, but coverage requirements vary.

Key factors to look for in your policy:

• Is breast reduction surgery covered under your plan?
• What criteria must be met (e.g., amount of tissue to be removed)?
• Do you need preauthorization before surgery?
• Are there specific medical documentation requirements?

If you’re unsure, call your insurance provider and ask for written confirmation of their breast reduction policy.

2. Prove Medical Necessity

Insurance companies typically approve breast reduction surgery when it is deemed medically necessary rather than solely for cosmetic reasons. You will need to demonstrate that large breasts (macromastia) are causing significant health problems, such as:

• Chronic neck, back, and shoulder pain
• Shoulder grooving from bra straps
• Skin irritation (rashes, infections) beneath the breasts
• Numbness or nerve pain
• Posture problems
• Limited ability to exercise or perform daily activities

3. Consult a Doctor & Gather Medical Records

To support your case, visit a primary care physician, plastic surgeon, or specialist (such as a chiropractor or orthopedic doctor). They can document your symptoms and provide medical records, which may include:

• Doctor’s notes describing pain and physical limitations
• Treatment history showing attempts at conservative treatment
• Prescriptions for pain medications or anti-inflammatory drugs
• Physical therapy records
• Photographic evidence of rashes, infections, or shoulder indentations
• BMI and weight history, if required by your insurer

4. Attempt Non-Surgical Treatments First

Many insurers require proof that non-surgical treatments have failed before approving breast reduction surgery. This may include:

• Physical therapy sessions
• Supportive bras and posture corrections
• Weight loss attempts, if applicable
• Pain management treatments (e.g., anti-inflammatory medications, muscle relaxers)

Make sure to keep records of all attempted treatments, as they strengthen your case.

5. Find a Board-Certified Plastic Surgeon

Choosing a board-certified plastic surgeon experienced in insurance-covered breast reductions can make a big difference. During your consultation, the surgeon will:

• Assess your symptoms and measure your breasts
• Determine the estimated amount of tissue removal (often required for insurance approval)
• Provide a letter of medical necessity outlining why surgery is the best solution

6. Submit a Preauthorization Request

Once you have all necessary documentation, your surgeon’s office will typically submit a preauthorization request to your insurance company. This request usually includes:

• A Letter of Medical Necessity from your surgeon
• Supporting documents (doctor’s notes, imaging, past treatments)
• Estimated tissue removal amount (often 500+ grams per breast)
• Photos (if required by your insurer)

The approval process can take several weeks. If approved, make sure to confirm what costs are covered and if there are any out-of-pocket expenses.

7. What to Do If Your Claim Is Denied

If your insurance denies coverage, don’t panic—many claims are initially rejected but can be approved on appeal. Here’s what you can do:

• Request a written explanation of the denial.
• File an appeal with additional medical records.
• Get supporting letters from specialists, such as an orthopedic doctor.
• Ask your surgeon to advocate on your behalf.

Persistence is key—many patients win appeals with the right documentation and persistence.

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Here’s a template for a Letter of Medical Necessity for insurance coverage of breast reduction surgery. You can customize it with your specific details:

To: [Insurance Company Name] [Insurance Company Address] [City, State, ZIP Code]

Subject: Request for Coverage – Breast Reduction Surgery (CPT Code: 19318)

Policyholder Name: [Your Name] Policy Number: [Your Policy Number] Group Number: [If applicable]

Dear [Insurance Representative’s Name],

I am writing to formally request preauthorization for a medically necessary breast reduction surgery (reduction mammoplasty) due to significant and persistent health issues caused by macromastia (overly large breasts).

I have been under the care of [Doctor’s Name], who has diagnosed me with [list relevant diagnoses, e.g., chronic back pain, cervical strain, shoulder grooving, rashes, etc.]. These conditions have significantly impacted my daily life and ability to perform routine activities.

Medical Necessity

I have been experiencing the following symptoms:

• Chronic pain in my back, neck, and shoulders, which has persisted for [duration], despite conservative treatments.
• Painful shoulder grooving from bra straps, worsening over time.
• Recurrent skin infections and rashes (intertrigo) beneath my breasts, requiring medical treatment.
• Limited ability to participate in physical activities due to excessive breast weight, impacting my overall health.

Conservative Treatments Attempted

I have attempted several non-surgical treatments as recommended by my healthcare providers, including:

• Physical therapy for [duration], with minimal relief.
• Prescription pain relievers and anti-inflammatory medications, which provide only temporary relief.
• Supportive bras and posture correction efforts, with no significant improvement.

Recommendation for Surgery

My physician, Dr. [Surgeon’s Name], has determined that a breast reduction procedure is medically necessary to alleviate my symptoms and improve my quality of life. Based on the recommended guidelines, Dr. [Surgeon’s Name] estimates that at least [estimated grams] of tissue will be removed per breast, meeting your plan’s criteria.

I kindly request that you review my case and approve coverage for this necessary procedure. Enclosed are supporting medical records, including:

• Physician notes and treatment history
• Medical imaging reports (if applicable)
• Documentation of failed conservative treatments
• Photos (if required by policy)

Please let me know if you require any additional information. I appreciate your time and consideration of this request and look forward to your prompt response. You may contact me at [Your Phone Number] or [Your Email] if further details are needed.

Sincerely,
[Your Name]

Breast reduction surgery can be life-changing, alleviating chronic pain and improving overall well-being.

While insurance approval may require effort, thorough documentation and strong medical support significantly increase your chances of success. If you’re considering breast reduction, start the process early and work closely with your doctor to navigate insurance requirements effectively.

For More Information on the Treatments and Procedures offered, contact award-winning Board Certified Plastic Surgeon Dr. Thomas Fiala at Fiala Aesthetics in Greater Orlando to Schedule Your Consultation:

Voted the #1 Best Plastic Surgeon in Orlando, Florida by the readers of Orlando Magazine.

Serving patients in and around Greater Central Florida: Orlando, Altamonte, Lake Mary, Maitland, Winter Park, Clermont, Casselberry, Lake Mary, Longwood, Celebration, Heathrow, Windermere, Dr. Phillips, Sanford, Deltona, Deland, Daytona Beach, Melbourne, Cocoa Beach, New Smyrna Beach, Ocala, The Villages and more.