Plastic surgery is a big business. The American Society of Plastic Surgeon’s (ASPS) annual report found that some $20 billion was spent in 2020, with 15.6 million cosmetic procedures and nearly 7 million reconstructive procedures performed. When we speak about the cosmetic end of the spectrum, we are usually dealing with out-of-pocket expenses because the treatments are generally considered elective and not medically necessary. When we talk about the reconstructive side of the industry, however, health insurance coverage may come into play.
In June 1989, the American Medical Association (AMA) adopted definitions of ‘cosmetic surgery’ and ‘reconstructive surgery’ that are used by insurance providers to determine coverage:
- Cosmetic Surgery: Performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
- Reconstructive Surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.
If you clicked on this article, it’s probably because you are considering a breast surgery of some kind. So, what does the ‘cosmetic’ versus ‘reconstructive’ distinction mean to you? If you are simply looking to up your cup size, you can pretty much count on paying for your breast augmentation yourself. But there are certain reasons why breast implants and other enhancement procedures may fall into the ‘reconstructive’ category. Additionally, breast reduction is one of the most common procedures insurance might cover.
To better understand what factors into whether or not a breast surgery is covered by insurance, we’re breaking down some of the key criteria you need to know to make your case.
Why Breast Surgery May Be Covered By Insurance
The fact of the matter is that there are no guarantees when it comes to insurance coverage. “Nobody knows what will qualify, as there are no guidelines that say, ‘if you have this, you qualify,” says Richard J. Brown, MD, a board certified plastic and reconstructive surgeon in Scottsdale, AZ. “It is totally at the discretion of the insurance company.” Even so, there are some circumstances that, with proper documentation, may mean a procedure is eligible for coverage.
1. Post-Mastectomy Reconstruction
Perhaps the most straightforward situation on the list, the 1998 Women’s Health and Cancer Rights Act mandated that group health plans that cover mastectomy (for both breast cancer prevention and treatment) must also cover breast reconstruction. It should be noted that Medicare covers bilateral breast reconstruction in post-mastectomy patients, too. Reconstruction can be performed in a variety of ways depending on the anatomy and aesthetic goals of the patient, and prostheses (i.e. breast implants) are an option. Whether it is a unilateral or bilateral mastectomy, insurance providers must cover reconstruction for both breasts.
In these cases, surgeons do not need to document symptoms or trials of alternative treatment. “For breast cancer, I do not have to document, as they already have a diagnosis,” Dr. Brown explains. “If it is for revision reconstruction, I document what I feel I can do to make the reconstruction better, if that is possible.”
2. Shoulder, Neck, & Back Pain
Anyone that suffers from back, neck, or shoulder pain knows just how debilitating it can be. Whether the pain is attributed to injury, poor posture, or breast size, treating the pain can be a challenge. This is especially true if the discomfort is caused by a large chest. Research has found a correlation between breast size and chronic back pain, and it is believed it may have to do with the curvature of the spine due to the weight of the breasts. As a result, insurance companies may cover a breast reduction to improve quality of life.
3. Inability to Exercise
Exercising is challenging enough as is, but, for some women, it is made even more difficult by large breasts. As you move, so do your breasts and that can be very painful while doing high intensity – or even low intensity – workouts. Finding sports bras that are supportive and containing enough may not be possible, with some even doubling up on them. Some women with large breasts are not able to get the health benefits associated with fitness, which can help create the case for a medically necessary breast reduction.
4. Significant Asymmetries
From head to toe, asymmetry is inevitable. No body – literally or figuratively – is perfect, and most females find that their breasts are uneven. For the large majority of people, correcting breast asymmetry is not a medical necessity. But for certain cases of asymmetry as a result of trauma, disease, infection, tumors, or genetic conditions that cause large size discrepancies, there may be a conversation to be had with your insurance company.
Chronic rashes under the breasts can be a reason for insurance to cover a reduction surgery. Because large breasts often droop and cover other areas of the chest, it can cause skin-to-skin friction (intertrigo) and/or make it difficult for sweat to evaporate. In normal circumstances, sweat produced in the inframammary fold (i.e. the breast crease) evaporates on its own, but, for women with larger breasts, the damp environment can cause irritation and rashes.
6. Bra Strap Grooves
Ever notice indentations on your shoulders when taking off your bra at the end of the day? It’s usually a sign that the undergarment was overburdened or ill-fitting. While this nuisance is usually a once-in-a-while thing for most, some bigger-busted ladies have permanent grooves from their bra straps because the breasts are simply too heavy to be properly supported. Alone, these markings may not be enough of a reason to warrant a reduction, but they can be supporting evidence (pun intended) when building a case.
Can large breasts be headache-inducing? According to research, the answer is yes. Studies show a link between chronic headaches and macromastia (large breasts), and women who previously suffered from headaches or migraines reported improved wellbeing post-breast reduction. The exact connection between the two isn’t fully understood, but it is believed that the weight of the breasts can be a stressor to the muscles in the head, just like in the back, neck, and shoulders.
8. Faulty Breast Implants
Just as insurance companies will cover breast implants for mastectomy patients, they may cover the removal of said implants if it is determined to be medically necessary to do so. ‘Medically necessary’ reasons can include:
- Implant rupture
- Severe capsular contracture
- Chronic breast pain
- Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
Even for reconstruction patients, coverage for breast implant removal or replacement is not a given. “Beyond initial reconstruction, insurance is not obligated to cover any breast reconstruction revisions,” Dr. Brown shares. But “the fact of the matter is they pretty much cover it all,” he adds. With that said, insurance companies rarely, if ever, cover revision if the primary surgery was for cosmetic purposes.
How to Build a Case for Insurance
So, how do you get insurance to cover your breast surgery? The reality of the situation is that it takes time and patience. With the exception of post-mastectomy breast reconstruction patients, evidence must be submitted to your insurance provider and pre-authorization must be gained before moving forward with the procedure. Insurance companies aren’t going to just pay for anyone’s breast surgery. In the case of reduction mammaplasty (a.k.a. breast reduction), you need documentation that demonstrates why you need the procedure, including some or all of the following:
- Photography: Standardized photography of the breasts taken by a medical professional is usually required to visualize the breast hypertrophy, or overgrowth of breast tissue.
- Symptoms: Chronic symptoms, like many of those listed above, must be experienced for at least six months (though usually a year or more) before building a case.
- Alternative Treatment: Proof of unsuccessful non-surgical treatments, including visits to a physical therapist, chiropractor, or orthopedist, supervised weight loss, or the inability for rashes or other skin conditions to be cleared up by a dermatologist, must be submitted.
- Surgical Plan: Your board certified plastic surgeon will need to share the approximate amount of tissue they plan to remove from each breast based on your weight and height. Insurance companies have specific parameters for how much needs to be excised in order for the reduction to be considered medically necessary.
- Surgeon’s Statement: Additionally, your medical team will need to share their opinion on why your symptoms are best treated with breast reduction surgery.
Not all health insurance companies will require all of these criteria be met, but, according to a 2020 paper published in Plastic and Reconstructive Surgery, pre-authorization denial rates for breast reduction surgery have increased steadily over the last five years. The researchers note that the factors for precertification “are used arbitrarily, without scientific evidence, and are inconsistent with clinical practice,” making it difficult for patients and providers alike.
These discrepancies are why Dr. Brown always tries to manage expectations. As he explains, “neck pain, back pain, bra strap grooves, headaches, rashes under the breast, [and] inability to exercise because they need several bras” are all legitimate reasons to consider breast reduction surgery, but these symptoms “do not guarantee” coverage by insurance. “They still can be denied,” he shares. “And often insurance wants proof of PT [physical therapy] and OT [occupational therapy] to avoid surgery.”
Needless to say, building a case for preauthorization isn’t something you do on your own. Your primary care physician, PT or OT specialists, and board certified plastic and reconstructive surgeon will all be part of the process. Dr. Brown’s approach? “I just tell the story,” he notes. “I describe the symptoms, and what is going on, and make comments on whether I feel it is medically necessary or not.”
In addition to the symptoms described above, insurance providers usually use the controversial Schnur Sliding Scale to calculate how much breast tissue should be removed. “[It] is a formula that based on height, weight, and other factors predicts how much they should have removed, and it is so imperfect,” Dr. Brown cautions. “They use that against how much the surgeon says they think they can remove, and, if those numbers are off by too much, they may deny.” Some insurance companies will also require the surgeon performing the procedure is in-network, so be sure to clear that up early on.
If your breast reduction case gets approved, insurance will cover the cost of the surgery – with some stipulations. You will need a post-operative report that shows the procedure was carried out in accordance with the pre-authorized plan. That includes being operated on by an in-network surgeon at an accredited facility (usually a hospital) and having the mandatory amount of tissue removed.
Unfortunately, there are no ‘sure things’ in insurance, but there are steps you can take to improve your chances of coverage. In addition to careful documentation, one of the best things prospective patients can do is work with a board certified plastic surgeon who specializes in the procedure they are interested in. They will likely have a lot of experience navigating the pre-authorization process, and they should also be expert in delivering the most medically and cosmetically pleasing result for your anatomy and aesthetic goals.
More Related Articles
‘Try on’ aesthetic procedures and instantly visualize possible results with AEDIT and our patented 3D aesthetic simulator.