Breast reduction may be covered by insurance in certain circumstances, depending on the patient’s medical symptoms, insurance policy, height, weight, breast size, and other factors. The body surface area, which requires knowing the height and weight, is used to help calculate the amount of breast tissue the surgeon needs to remove to meet the insurance company’s criteria for payment of the services rendered. The surgeon has to estimate preoperatively the right amount to remove and calculate it against a sliding scale used by most insurers. Insurance companies also require documentation of symptoms associated with the heavy breasts in order to approve the procedure.
These include:
Neck and back pain not attributable to other causes (like slipped discs)
Shoulder grooves from the bra straps
Difficulty finding properly fitting bras
Rashes under the breasts
Psychological embarrassment
Failure of improvement of symptoms with physical therapy, supportive bras, and other treatment methods for several months to over a year
Usually the surgeon’s office will need to submit photos as well as documentation to your insurance company ahead of time to obtain authorization for the surgery, including the estimate of the breast weight to be removed. If approval is denied, an appeal can be filed but there is no guarantee of successful approval on appeal. Medicare beneficiaries considering a reduction may be asked to sign a waiver to self-pay for the procedure if Medicare denies coverage, as Medicare does not have a pre-authorization pathway like third-party insurance companies do.