Will Insurance Cover My Breast Reduction Surgery?

houston insurance breast cancer

Will Insurance Cover My Breast Reduction Surgery?

Breast reduction surgery is often more that cosmetic – patients requesting this procedure may also be suffering from uncomfortable physical symptoms due to disproportionately large breasts. For some of these women, the procedure may be deemed “medically necessary” by their insurance company, which allows them to use their coverage for their procedure. However, the formulas used by insurance companies to determine medical necessity can be complex and it is important to understand the factors involved before you schedule your breast reduction procedure.

Physical Symptoms and Non-Surgical Treatments

Large breasts can cause a number of uncomfortable symptoms, including:

  • Back, neck and shoulder pain
  • Painful grooves from bra straps on shoulders
  • Skin irritation and rashes beneath the breasts
  • Numbness in the arms and hands

Physical symptoms typically must persist for a set period of time, as determined by the insurance company. In addition, many companies require women to try non-surgical treatments for their symptoms first, such as oral pain medication and physical therapy, before surgery is considered a viable options.

Numeric Formulas

In addition to physical symptoms, most insurance companies use a numeric formula to determine the medical necessity of breast reduction. The Schnur scale is commonly used for this purpose, which takes into account body surface area in relation to the amount of breast tissue to be removed. Patients that fall above the 22nd percentile according to this scale may qualify for insurance coverage of their reduction surgery.

Breast Cancer Rules

If a woman is seeking breast reduction to make her breasts symmetrical after breast cancer surgery, insurance companies are required by law to provide coverage for that reduction procedure. Protections for these services were created by the Women’s Health and Cancer Rights Act of 1998. The purpose of the act was to guarantee coverage for full reconstructive procedures for women facing a mastectomy after a breast cancer diagnosis.

Providing Documentation

Even if your breast reduction surgery meets the criteria for insurance coverage, proper documentation will need to be provided to obtain approval from the insurance company for the procedure. This documentation usually includes photographs, a list of symptoms and treatments already performed, a letter from your physician describing your physical symptoms and an assessment of your condition based on the Schnur scale. It is important to provide the documentation prior to your procedure, in case your insurance company requires pre-authorization to cover surgical procedures.

At Houston Center for Plastic Surgery, we work with patients to help them understand their insurance options. To learn more about breast reduction surgery or coverage possibilities for this procedure, contact Houston Center for Plastic Surgery at (713) 790-4500.

Houston Center For Plastic Surgery

6560 Fannin Street, #1812
Houston, Texas 77030

Phone: (713) 790-4500
Fax: (713) 793-1299
Email: info@hcps.cc