Insurance Coverage

Having an Insurance Company Cover the Cost of Breast Reduction Surgery

Getting your insurance company to cover anything these days can be quite a challenge. In order to get approval from insurance companies, a plastic surgeon, and the patient, must meet a certain criteria.

Criteria to Meet Insurance Companies Requirements

First, your plastic surgeon must estimate that he or she can remove at least 500 grams (one half to one pound) from each breast. Your surgeon must also show that you have disabling symptoms directly attributable to your large breasts, and your plastic surgeon must show that you have tried everything under your power to resolve the macromastia symptoms yourself. Along with this your plastic surgeon must provide photos documenting the need for this operation. Only then will there be a chance that surgery will be pre-authorized by your insurance company. And yet, the likelihood of insurance coverage for this problem remains small.

Further Requirements and a Catch-22

Most insurance companies now also require that the woman requesting this operation be at or near her ideal body weight. Unfortunately, this is where the catch-22 appears again: Women with macromastia are often unable to exercise because their large breasts are too cumbersome to allow it. So, they are unable to lose the weight necessary to satisfy the insurance company’s requisites for pre-authorization.

Of course, even though it may seem unfair that you and your surgeon are made to jump through such hoops, it is critical that both you and your surgeon include only honest information in your letter to the insurance company. Also, remember that even if your insurance company pays for the procedure and even if you use an in-network physician, you may still be responsible for a portion of the cost (check your insurance policy to find out).

Dr. Loftus performs many breast reductions, but does not accept insurance. Many women report that their deductible is higher than the cost of having the procedure performed by Dr. Loftus, and so, even though they have insurance, they find that they save by having it performed by a doctor who does not take insurance. Again, this is because the charges and deductibles are often higher when one goes through insurance.