Breast Reduction Surgery: Is it Reconstructive Surgery, Cosmetic Surgery or Doesn’t It Matter? Will my health insurance cover the surgery?

I recently saw a female college student, as a new patient consultation concerning “Breast Reduction Surgery”. This procedure also known as “Reduction Mammaplasty” is indicated for the treatment of symptomatic macromastia (large breasts). The commonly reported symptoms related to macromastia are that of: neck, shoulder and back pain secondary to the weight of the large breasts upon the musculoskeletal system. Other secondary symptoms include: breast pain and dermatitis or rashes beneath the breasts.
This above patient was referred by her gynecologist and arrived with a “prescription” recommending a consultation with a “plastic surgeon”. The patient believed, as many do, that since she was referred by her physician, that the surgery would be covered by her health insurance plan. She was requesting that the surgery be scheduled in four weeks, during her “winter recess” from college.
After completing a patient history and regional breast examination, my staff proceeded to explain to her the procedure necessary to try and obtain insurance authorization for her requested and indicated surgery. She had no other medical treatment or consultations concerning her macromastia. No history of being referred for physical therapy, chiropractic treatment, orthopedic consultation, or dermatology exam. The patients understanding of the “health insurance system” was that, if her referring physician recommended her for treatment, it must be a medically indicated and covered procedure.
Reconstructive Surgery vs. Cosmetic Surgery: It is universally believed by patients, that if a surgery is classified or considered “reconstructive”, it is medically indicated and an insurance covered procedure. This usually means to patients, that all fees related to that procedure will be paid by their health insurance. And if a procedure is considered “cosmetic”, it is not a medically indicated and covered procedure. It is my opinion that for years, breast reduction surgery has been thought of as a “Hybrid”. It is considered “reconstructive” in attempts to obtain insurance coverage for the surgery. It is considered “cosmetic” in that patients expect meticulous aesthetic expertise in the surgery and the post-surgical results. In our practice, it has recently become extremely difficult to obtain insurance coverage for breast reduction surgery. Insurance companies frequently require 2-3 documented reports from other referred specialists. Also the insurance companies commonly requests 6-12 months of documentation and treatment by either a: physical therapist, chiropractor, dermatologist or orthopedist.
Do Your Homework: The intent of this blog is simple and I hope that everyone who reads it understands one point. If you feel that you are a candidate for breast reduction surgery, and requesting coverage under your health insurance, it is important that you contact your health insurance carrier, and have them forward to you in writing, what their criteria are for coverage. Every insurance company has difference, independent criteria and indications, and one should not confuse the fact that “my friend” got it covered by her insurance, and she had “smaller breasts” than me. On the average, it takes between 3-6 months of preparation, seeking secondary consultations with other healthcare providers and possible therapy (physical therapy or chiropractics). Notify your primary care physician as soon as possible concerning any symptoms which may be related to your macromastia. It is never too early to start the process, and remember that what the insurance company’s criteria are this year might not be the same next year. Please contact our office concerning any questions you might have that relate to breast reduction surgery and coverage through your health insurance.