San Francisco, CA-Due to all the medical problems that having large breasts, also known as macromastia, can cause (see previous blog), many health insurance policies will cover all or part of breast reduction surgery. However, it is getting more difficult to get approval and with all the changes with health insurance it may become even harder.
In the meantime, if you have a policy that specifically has an exclusion for breast reduction surgery there isn’t much you can do except get a different policy. If you work for a company that offers medical insurance, review all insurance plans offered and switch to one that will cover the cost of breast reduction surgery during the open enrollment period (which is usually in November). The new insurance will probably cost more, but then you can switch back to your previous one at the next open enrollment.
If your insurance does not have an exclusion, that’s a big plus, but you still may have a few hoops to jump through to get approval. Understanding what most insurance companies require and why makes it a little easier to go through the process.
The insurance company will want to know what you have tried to help alleviate your symptoms. For example, have you invested in high quality support bras? For many women, even with top quality bras, they end up with shoulder grooves from the straps which
themselves can be painful. Next, have you tried physical therapy including exercises to strengthen your back muscles to help counteract the additional weight carried on your chest? Have you tried anti-inflammatories to ease back, neck and shoulder pains? It is unlikely that these methods are going to give you any lasting relief, but the insurance company will want to know as they are not anxious to give approval. You can expedite your approval process if you have documentation of all these things ahead of time. Get a letter from the physical therapist, receipts for bras, a letter from your General Practitioner that you have tried anti-inflammatories.
Another requirement some insurance companies have is that you need to be within a certain weight range, and if you are above the limit they may not cover your reduction mammoplasty procedure until you lose weight. This is understandable because for many women when they lose weight they will also lose fat in their breasts, and the back pains may have resolved themselves; therefore, surgery will not be covered. Not only will their breast reduction surgery not be covered, they are left with droopy sagging breasts, and if they desire a breast lift, that won’t be covered either as it is considered cosmetic surgery. Insurance companies will not cover a procedure they consider cosmetic unless it is causing physical pain and/or complications; psychological distress is not considered a reason to cover a procedure, such as gynecomastia, which is male breast reduction.
Losing weight can be very difficult for many women with large breasts as exercising is a challenge. It is important to note that large breasts are not only due to excess fat, for many women it is a combination of fat and tissue and, therefore, losing weight may not make much of a difference.
Having a consultation with a Board Certified Plastic Surgeon who specializes in breast surgery will be your best option. Your surgeon is very familiar with all the ins and outs of the insurance companies and will be able to advise you on the probability of getting coverage.
In addition to all of the requirements mentioned above, one of the main requirements of the insurance company will be how much tissue is needed to be removed. Most say it must be 500 grams per breast or more, otherwise they consider the procedure to be cosmetic in nature, and they will not cover it. Your surgeon will be able to tell you approximately how much tissue you would need to have removed and the probability of your qualifying.
Even after all of these steps have been taken there have been cases where the insurance company has turned down their clients for surgery. While this is extremely frustrating, don’t give up just yet! The next step would be for your surgeon to appeal your case; this can be more successful than you might think. When an appeal is requested, the insurance company brings in an impartial medical doctor to review the case. The doctor will contact your surgeon to discuss your issues. Many times after the surgeon and doctor consult the denial is reversed, and surgery is approved!
Dr. Delgado has had many years of experience with situations such as these, successfully obtaining approval from insurance companies on behalf of his patients.