Will My Insurance Cover Breast Reduction?
Are you interested in breast reduction surgery and are unsure if your insurance plan will cover the operation? Are you unsure if you qualify for a breast reduction covered by insurance? Our expert insurance management team at Richmond Aesthetic Surgery is here to help. Our excellent team is here to answer all of your questions regarding insurance-covered breast reduction surgery and to guide you through the process of approval.
Insurance Coverage for Breast Reduction and “Medical Necessity”
Many insurance plans cover “medically necessary” breast reduction. Depending on the details of your surgery, your insurance may cover part or all of your breast reduction cost. In fact, around 75% of patients who have a consultation for the procedure may qualify for insurance coverage. This is due to the medical need to reduce breast volume and weight.
Common problems women seek to alleviate with a breast reduction include neck and shoulder pain, back pain, skin rashes beneath the breasts, nerve entrapment and numbness of the arms and hands, and grooves from bra straps. Whether insurance covers a breast reduction will depend upon the duration and severity of these symptoms. It will also depend upon the insurance carrier. Each insurance carrier has its own criteria for what it considers medically necessary.
Criteria for Medical Necessity
At Richmond Aesthetic Surgery, Dr. Zemmel and his team will perform a complete history and physical at your initial consultation. He will take detailed measurements and determine which surgical technique is right for you. Dr. Zemmel will also determine how much tissue in grams can be removed to help your symptoms and make you feel much better.
Each insurance carrier has different criteria to determine medical necessity. Some insurance carriers require a certain amount of tissue to be removed based on your height and weight and Body Surface Area (BSA). The Schnur Scale is used to correlate your BSA with the amount of required tissue for removal. The Schnur Scale has been used for decades to determine the amount of tissue needed to be removed to improve your symptoms. The larger the BSA, the more tissue is needed to be removed.
If you are considering breast reduction, you should first read your insurance policy. For some, a “reduction mammoplasty” (breast reduction) may be a policy exclusion, which means the surgery is not covered despite being medically necessary. By understanding and preparing for the insurance process, you can navigate the approval journey more smoothly and ensure you receive the coverage you need for your breast reduction.
The highly skilled and professional Insurance Management team of Richmond Aesthetic Surgery will guide you every step of the way.
What Insurance Carriers Are Accepted at Richmond Aesthetic Surgery?
Below is a list of common insurance carriers Richmond Aesthetic Surgery currently accepts:
Anthem/BCBS
We accept Anthem/Blue Cross Blue Shield (BCBS), one of the most widely used insurance providers in the country. BCBS may provide coverage for breast reduction surgery if it is considered medically necessary to relieve symptoms such as back, neck, or shoulder pain.
Aetna
Our practice accepts Aetna insurance plans for breast reduction procedures that meet the criteria for medical necessity. Aetna typically requires documentation of physical symptoms and attempts at conservative treatment prior to approval.
Cigna
Cigna insurance is accepted at our practice and may cover breast reduction surgery when patients experience chronic discomfort or skin issues related to overly large breasts. We can help guide you through Cigna’s pre-authorization and documentation requirements.
United Healthcare
We work with United Healthcare to help patients access coverage for breast reduction surgery that is deemed medically necessary. United Healthcare often approves the procedure when symptoms like persistent rashes, posture issues, or pain significantly affect quality of life.
Many other insurance plans from smaller carriers are also accepted. If your insurance carrier is not listed above, our team will be happy to help you determine your coverage benefits and your level of coverage.
What Steps Are Required to Obtain Insurance Coverage?
To increase the likelihood of your breast reduction being approved by your insurance, thorough documentation is essential. This includes:
1. Letter of Medical Necessity from Your Plastic Surgeon Dr. Neil Zemmel
Before your breast reduction surgery is scheduled, most insurance providers require your surgeon to write a letter detailing your symptoms, physical assessment, and the approximate amount of excess breast weight, as well as the request for coverage. If insurance coverage is denied due to the procedure being considered cosmetic in nature, your surgeon can inform the insurer of your medical need and how reduction differs from a breast lift, which is considered cosmetic.
2. Photographs of Your Breasts
Pictures are necessary to illustrate the physical issues caused by the size of your breasts, helping your insurance company understand the medical necessity of the procedure. The pictures are taken to document grooves created by your bra straps, the size of the breasts, skeletal abnormalities, and skin rashes. These pictures will be taken in the office during your consultation with Dr. Zemmel and will be completely protected and private. No identifying information is included in the photo.
3. Visits with your Primary Care Physician, Chiropractor, or Physical Therapist
Detailed medical records are needed to help support your insurance claim for breast reduction surgery. These should document your chronic symptoms like back, neck, or shoulder pain, and any skin rash issues. Please also document any symptoms of numbness in the arms and hands. Include any records of prior treatments, such as physical therapy or pain management, skin rash treatments and topical medications. This greatly helps demonstrate the medical necessity of the surgery, increasing the likelihood of insurance approval. The insurance management team has a sample letter you can give to your provider for completion.
Insurance Authorization
How Long Does It Take to Get a Breast Reduction Approved?
The approval process for breast reduction surgery varies by insurance provider and policy. It begins with a consultation where your surgeon assesses your condition and recommends surgery based on potential medical necessity. This recommendation, along with the detailed documentation explained above, is submitted altogether to your insurance company.
Approval can take anywhere from a few weeks to a few months, depending on how quickly your insurance processes the request and whether additional information is needed. To expedite approval, ensure all required documentation is complete and submitted promptly. Our office can help navigate these requirements and communicate with your insurance provider.
What if My Insurance Denies My Breast Reduction Coverage?
If you receive a denial but feel a reduction is necessary for your day-to-day living and overall health, you have the legal right to send an appeal. How you can go about this appeal process should be explained in your denial letter. It can be helpful for you to write your own letter describing the side-effects of your overly large breasts and how they prevent you from normal daily function, emphasizing your chronic physical symptoms.
Also helpful, you should obtain a letter from other health professionals, such as a family doctor, physical therapist, chiropractor, or orthopedist, to further support your appeal. You can ask your doctor to submit these letters as well as the latest scientific findings and medical publications about the permanent treatment of breast reduction to create a strong argument against your denied coverage.
Does Medicaid Cover Breast Reduction Surgery?
Yes, Medicaid can cover breast reduction surgery if it is deemed medically necessary. Coverage criteria include chronic pain in the back, neck, or shoulders, skin irritation, or infections that do not respond to other treatments. The specific requirements for approval can vary by state. Comprehensive documentation from a healthcare provider, including medical records and possibly photographs, is essential to support the claim. Richmond Aesthetic Surgery accepts Anthem/BCBS Healthkeepers Plus Medicaid.
Out-of-Pocket Self-Pay Costs
If you have a policy exclusion for breast reduction (your insurance company simply does not cover it), or if your insurance carrier upholds the denial, Dr. Zemmel and his team can give you an out-of-pocket quote for the procedure. Approximate fees typically range as follows:
| Surgeon’s Professional Fee: | Operating Room Costs: | Anesthesia Costs: | Total: |
|---|---|---|---|
|
$7,500–$12,000
|
$2,000–$3,000
|
$1,500–$3,000
|
$11,000–$18,000
|
Breast Reduction Financing Options
In the event of a denial, Dr. Zemmel and the team will assist you in financing your surgery if necessary. After you have had the chance to consult with our plastic surgeon, you will be provided with a quote of how much you can expect to pay. Should the estimated cost of your breast reduction be outside of your budget, our staff can work with you to find a way to make the procedure more affordable.
Our practice offers financing through CareCredit® and Cherry to help make your breast reduction a reality. These companies provide a variety of low monthly payment plans and different interest rate options to help you find the best financing for your situation.
The application process for Cherry is quick and provides instant approval options without any hidden fees. Applying for CareCredit® is also typically a fast, simple process, and you can do so over the phone, online, or by fax. If you have any difficulty applying for financial assistance, our knowledgeable staff can help guide you through the process.
Schedule Your Consultation
If you have any questions or concerns, please feel free to contact us, and one of our team members will be happy to assist you.
