Breast Reduction: Does Insurance Pay for the Procedure?

April 23, 2014


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RssLKGnGARPgV3IjYfjK2bsFAKMsqdGO_jvh7csg3TgLarge breasts can be more than a mere cosmetic concern for some women. The extra weight of the breasts can strain back and shoulder muscles and cause painful chafing in the breast creases. Those who suffer symptoms may be diagnosed with symptomatic macromastia, a condition that can be surgically treated. Insurance coverage is often available for breast reduction surgery (reduction mammoplasty) as long as specific criteria are met.

Symptoms of Macromastia
Women who have symptomatic macromastia may suffer from one or more of the following:

Pain in the neck, shoulders and upper back
Rashes/infections, caused by chafing or moisture of the skin under the breasts
Grooving in the shoulder from bra straps
Numbness in the hands or fingers
Difficulty fitting into bras or clothing
Difficulty working out because of the size of the breasts

Often the painful symptoms send women to their primary physicians for relief. The good news is that patients who have documented symptoms as a result of their large breasts often meet the criteria for insurance coverage.

Qualifying for Coverage
Insurance companies often cover reduction mammoplasty procedures when patients have a documented history of any of the above symptoms. However, other criteria may also need to be met by the patient and surgeon, including:

Body Mass Index Restrictions – Some insurance companies will not cover the procedure for patients with a BMI greater than 30 or 35, since the higher BMI may indicate weight loss could help to improve the symptoms.

Weight of Breast Tissue – While the weight of the breast tissue provides indications of breast size; it does not offer information about the relationship between breast size and a woman’s body size. Some insurance companies may use a formula to make this correlation to determine whether the breasts are large enough to warrant surgical treatment relative to a patient’s body surface area (“Schnur Sliding Scale”).

Physician Letter – This letter usually comes from a primary care physician or other provider that has treated a patient’s symptoms associated with breast size in the past.

Photographs and Other Documentation – Photos of the breasts and specific measurements that show breast size in relation to body size may also be required by some insurance companies.

While the criteria can be extensive, a plastic surgeon specializing in breast procedures can help a patient determine whether they meet the common criteria for insurance for breast reduction surgery. To learn more about breast reduction, or insurance coverage options for the procedure, contact the Physician’s Clinic of Iowa Plastic Surgery at 319-382-8230.

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