Patient can determine how many grams will need to be removed in order for insurance to deem this surgery as medically necessary.
Breast reduction or Reduction Mammaplasty, is a procedure to remove excess breast fat, tissue, and skin to achieve a breast size that is more in proportion with your body as well as to alleviate any discomfort that comes along with overly large breasts.
For some women full breasts are an asset, but in some instances a woman’s breasts are so large, heavy, and out of proportion to their bodies that their breasts can cause issues, including neck, back and shoulder pain, difficulty exercising, bras or clothes that don’t fit properly, and skin irritations or rashes.
If you are considering breast reduction surgery and are wondering if insurance would cover this surgery here is some helpful information to consider.
Most insurance carriers will offer breast reduction covered by insurance if it meets certain requirements to be deemed “medically necessary.” Traditionally the main point an insurance company considers is the amount of tissue to be removed from each breast. Most major insurance companies have established basic criteria as to the amount of tissue that must be removed relative to a person’s height and weight. While there is no set amount to qualify with insurance, generally if the breasts are reduced by less than two cups sizes its is categorized as a cosmetic breast lift and not an insurance covered breast reduction.
In some instances, insurance companies also consider what other health concerns are caused by large breasts, such as, back and neck pain, skin rashes, and bra strap indentations. Sometimes documentation from other providers such as Primary Doctor, Chiropractor, Dermatologist can be helpful in explaining to the insurance company that Breast Reduction surgery is medically necessary.
Most major insurance companies provide insurance coverage for breast reduction, but there are several factors that must be looked into in order to determine if you are eligible for coverage. Dr. Bowen at Golden Isles Center for Plastic Surgery encourages you to contact your insurance company and ask questions in order to find out what your specific insurance plan covers. A few questions to ask include:
-Do I have surgical benefits?
-What factors are required to determine if breast reduction surgery is medically necessary?
-What documentation is needed to show “medical necessity?”
While you are on the phone with your insurance company I would also ask the following to determine what might be your out of pocket expense for a surgery like this:
-What is my deductible? How much is left on my deductible?
-Do I have co-insurance? If yes, what is that percentage?
-Do I have a copay? If yes, how much is it for a specialist?
When you come to Golden Isles Center for Plastic Surgery for your initial consultation, Dr. Bowen will conduct a thorough examination of your breasts. During this consultation Dr. Bowen will determine how many grams of tissue will need to be removed to make your breasts proportional to your body and alleviate any health concerns. Once this has been determined, we will submit this information to your insurance company to determine if Breast Reduction surgery is medically necessary and approved.
Most insurance companies use a simple, standard calculation to determine your body surface area or BSA. Height and weight are used to make this calculation. Once your BSA is determined, it is compared to the Schnur Sliding Scale chart. The Schnur Scale chart is an evaluation method used when considering breast reduction. This evaluation method was developed by a plastic surgeon who was studying women who required breast reduction surgery for medical reasons. The sliding scale is a chart that takes into account the patient’s body surface area and the average weight of breast tissue that would need to be removed. A breast reduction surgery is deemed medically necessary if the patient’s body surface area and weight of breast tissue removed are above the 22nd percentile. If they are below the 22nd percentile, the breast reduction is considered a cosmetic breast lift and not deemed medically necessary.
Call today to schedule a consultation to discuss your specific needs! 912-634-1993.
Breast Reduction FAQs
Breast reduction surgery is appropriate for healthy women of all ages. Your breasts should be fully developed, and you should be at your ideal body weight. Women who are planning future pregnancies can be candidates also but keep in mind that pregnancy and breast feeding can change the shape and size of the breasts and future surgeries may be required.
- Reduction in neck, back and shoulder pain
- Rashes and skin irritations of the skin under the breast
- Reduction in the deep shoulder grooving due to bra straps
- Reduction in the size of areolas
- Improvement in posture
- Improvement of sagging, stretched out skin and breast asymmetry
Breast Reduction surgery will remove excess fatty tissue making the breast smaller and more proportional to the body resulting in breasts that are perkier and shapelier. Other benefits include:
- Improved or eliminated pain and other physical discomfort
- Increased exercise ability
- Better bra and clothing options
- Improved self-confidence and body image
In some instances, insurance will cover a Breast Reduction surgery, however each insurance has its pre-qualifying factors in determining if this procedure is “medically necessary” for you. The insurance company also determines how much breast fat, tissue and skin needs to be removed and in some instances that can leave you with very small breasts that would not be proportionate to your body either. In these instances where you do not fit insurance qualifications then this would be considered a cosmetic procedure.
Most women can return to a non-strenuous job after 3-5 days. In some cases, a drain tube may be inserted to reduce fluid accumulation and swelling. This is typically removed at the first postop visit (within one week). You will be directed on the appropriate bra to purchase postoperatively. It is important to avoid exercise and heavy lifting for 4-6 weeks. Some women will experience temporary nipple numbness due to swelling that may takes months to return. It is rare to have permanent nipple/areola sensation changes.