I feel like I need to preface this article about getting insurance to cover breast reduction surgery by saying this- all insurance plans are different and what is acceptable for some might not work for others, so be sure to check with your provider to see what you need to do!
I had experience working with three different insurance providers over the course of trying to get my surgery and I’ve done a lot of research, so I have a pretty good understanding about what even the most strict policies will require and I wanted to pass along all of my tips and knowledge to help any of you trying to navigate this process.
**I live in the U.S. so this may be totally different in another country**
First things first
The quickest way to find out what your insurance provider’s policy is about covering breast reduction surgery is to just call and ask, they MIGHT be able to tell you.
Now, when I called I was told that they couldn’t give me that information because it “depended on the scope of work” and that the doctor would need to send a request.
Schedule your consultation
Most insurance plans need to know that your procedure is considered medically necessary to be able to cover your breast reduction. Additionally, they usually require for a certain percentage or amount of breast tissue to be removed in order to qualify. To know for sure if you will be having that amount removed and that the surgery will be a medical benefit, you will need to schedule a consultation with your surgeon and determine what your surgery will look like, because it’s different for everyone.
Your doctor will be able to determine how much breast tissue will be removed, what kind of surgical assistance you’ll need, they type of surgery that will work best for you (there are a few ways to perform breast reduction!) and give you a good idea about what you can expect and whether it has potential to be approved.
(If you want to hear all about my consultation, I created a video you can watch here!)
Usually they will put all of this information into their system and submit a claim to your insurance to see if the procedure will be covered. Some insurance plans will respond immediately and say the procedure is covered, some will respond that the plan does NOT cover insurance (if it’s not part of your policy), and very commonly, some insurance plans respond and request additional documentation to show that the procedure is medically necessary. Even if your surgeon has told them you’ll benefit from the surgery, they might require the extra documentation.
Related: Things No One Told Me About Breast Reduction Surgery
What types of documentation will they need?
When they ask for supporting documentation, what they want to see is either medical records or notes from doctors specifically stating medical problems that are directly related to having large breasts. They may also want to see proof that you have tried other methods of relieving the pain prior to getting surgery.
For example, you will want to get documentation showing that you have a medical history of headaches, neck pain, back pain, and shoulder pain, and that you have tried other treatments such as taking OTC pain medication and this has not helped.
Here is a list of the most common medical issues that insurance companies will consider:
- consistent neck, back, and shoulder pain
- headaches and migraines
- tingling or numbness in the arms and hands
- difficulty breathing at night or when lying on back
- permanent indents on shoulders
- kyphosis or scoliosis- a curvature of the spine
- recurring skin conditions underneath bra line
- difficulty in performing regular daily tasks such as exercising or household chores due to large breasts
Here is a list of the most common treatments that insurance companies might recommend trying or that they’ll need proof that you’ve tried before approving your breast reduction surgery:
- wearing a back brace
- taking OTC medication for headaches and pain
- massage therapy
- physical therapy
- visiting a dermatologist for skin conditions
- weight loss for overweight patients
Typically an insurance company that requires additional documentation will request some form of proof that you have 2 or more of these conditions, and that you have tried treatment for those conditions that has been unsuccessful.
How to get the supporting documents
This is where you will want to schedule an appointment with your normal doctor and talk about some of the issues you have had. The doctor can make notes in your medical file or they can write an official letter stating you have these conditions to provide you with the proof/documentation the insurance company will request.
In your letter, the doctor will also need to include the treatment measures you have taken to help with those issues, for example if you’ve had back pain, that you’ve tried physical therapy and OTC medication and both have been unsuccessful in helping with your pain.
Once your doctor has written up that note/letter, it needs to be sent to the insurance company for consideration. My doctor and surgeon were both in the same medical network, so he was able to send a letter directly to her, and she submitted it to the insurance company.
Related: How To Know If A Breast Reduction Is Right For You
The waiting game
After your documentation has been submitted, it’s a waiting game to see if they’ll approve your surgery. Some insurance providers take as little as a few days to get back, others take a couple of months even.
When I started considering breast reduction surgery, my insurance provider took 6 weeks to respond, and unfortunately they did not cover surgery as part of my plan period, regardless of the medical necessity. Bummer.
At that point, we switched to my husband’s insurance plan with his company (he had gotten a new position so we were able to do it mid-year for the “life change event”), and I had my doctor submit the request with supporting documentation again. This time, it took about 10 weeks to hear back from them, at which time they responded that they required me to try 6 months of physical therapy and OTC medication first before they would cover the surgery.
If I had continued with that plan, I would have done the physical therapy, gotten a note from my doctor that I had completed this and the results were unsuccessful, and then submitted the claim again to insurance for approval. My understanding is that at that point, that would have been enough to approve it, but I ended up getting a new job and switched my insurance provider again to my new plan with my new employer.
So with the new insurance, I had my doctor submit a new claim and the supporting documentation. The new insurance provider responded within about a week that they needed documentation of my kyphosis, so I went and had an x-ray for that and we submitted that to the insurance. Within about another week, they approved the procedure and I was able to schedule a time to have the surgery with my doctor. So for me, submitting my claim to the insurance company that paid for my breast reduction surgery took about two weeks total before it was fully approved.
Related: All the Dirty Details of My Breast Reduction Surgery
If the surgery is not approved…
Find out the reason why! If it is not part of your plan, unfortunately the only option may be either to change plans or upgrade (at the new enrollment period or with a life-changing event). If they declined it because they did not deem it medically necessary, you may still be able to work with your doctor to provide them with additional information that it IS medically necessary and get the surgery approved at that point.
The other option is to pay out of pocket. Now this number varies HUGELY for every single person and with every doctor, because each circumstance is so individual! However, in all of my research, I found that it seems like the majority of the time, breast reduction surgery floats somewhere between 5k and 9k when you pay out of pocket, depending on your needs and your doctor.
If the surgery IS approved…
Congratulations! Your doctor should be scheduling a time with you to get the procedure. You will want to keep in mind that the insurance will likely only cover the procedure if you meet the minimum requirements for breast tissue being removed, usually they take a percentage of your BMI or require a certain gram amount based on your size- and you MUST meet those minimums or they won’t pay. Keep that in mind if you are only wanting to remove a small amount.
Breast reduction has been the absolute best thing I’ve ever done for myself and my life is totally different and better for it! If you want to read all about the dirty details of my breast reduction surgery, you can find that here. If you want to learn more about the things I didn’t expect with my surgery, you can find that here. And if you’re looking for just some more general information and want to know if breast reduction is right for you, read more here!
Don’t forget, I post all the time on instagram and have regular updates, come follow me! I’d love to connect!