Will insurance cover my breast reduction?

Breast reduction is one of the most popular procedures that plastic surgeons do, and typically breast reduction patients are very happy with their results.  It is one of the few plastic surgery procedures that is covered by insurance.  However, patients must meet a number of criteria before their insurance will pay for this surgery. 


The medical indications for breast reduction include chronic back, neck and shoulder pain as well as intertrigo, or yeast infection, caused by large breast size.  Typically, a patient needs to have these problems documented by their primary care physician over a period of time, as well as attempts to treat these problems without surgery, such as anti-inflammatory medications, physical therapy, and anti fungal treatments.  Only after patients have tried other treatments and continue to have problems will insurance consider coverage.  ​

In addition, most insurance companies have a scale that requires a certain weight of breast tissue to be removed relative to the patient’s overall height and weight.  

So, if you are hoping to have a breast reduction covered by insurance, you should have already seen your primary care doctor to address these problems before making a trip to the plastic surgeon’s office.  Once you have seen your plastic surgeon, and you have both decided that breast reduction surgery is a good idea, then all of these records must be submitted to the insurance company for approval.  This process can take weeks to months, and each plan has different requirements, so patience is required. 

My breast reduction was approved by insurance, how much will I have to pay?

If you are fortunate enough not to have used your health insurance for any major problems before now, then you may not be familiar with how your plan works.  There are hundreds if not thousands of different plans, and you as the patient are responsible for understanding your own plan.  Your plastic surgeon can try to help you to estimate costs, but there are some barriers to getting an exact amount prior to surgery.  

Why is this? And how does insurance work?

First of all, you will have a deductible.  This is the amount that you will have to pay before your insurance starts paying any of the cost.  Often, this amount will be collected before surgery, since it is known that you will have to pay this cost.  Next there is often something called co-insurance, which will be a percentage.  If co-insurance is 20%, then you will have to pay 20% of any additional costs beyond the deductible until you hit your out of pocket maximum for the year.  

Why can’t we tell you how much this is?  Good question.  

The main reason is that the insurance companies have different contracted rates with each hospital and each physician, which are kept secret.  Second, until the claim is submitted after surgery, we cannot be sure what will actually be covered, even with the pre-approval in place.  Crazy? Yes.  This is the reason why more and more physicians are no longer accepting insurance plans.  

A good rule of thumb is that you should expect to pay anywhere up to your yearly out of pocket maximum for a surgical procedure.  With more and more patients using high deductible plans, even if your insurance covers your breast reduction, you may pay a similar amount as doing a cosmetic procedure, however, it is still helpful to meet your deductible or out of pocket costs in the case that you or your family members have any other health expenses during the year. 

This Post Has One Comment

  1. Mary Kay

    Approximately how much (what range) is a breast reduction if you are not using insurance?

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