Insurance Coverage for Breast Reduction

Does insurance cover breast reduction?

It can, when the surgery is medically necessary rather than cosmetic. Everything rests on how well the medical case is made. That is the difference between an approval and a denial, and most of that work is done by your surgeon.

Symptomatic macromastia: the term your insurer is looking for

Macromastia means large breasts. The word that matters to your insurance company is symptomatic, meaning your breasts are causing you real physical problems, such as:

• Neck, shoulder and upper back pain
• Painful grooving or indentations where your bra straps sit
• Rashes and skin irritation beneath the breasts, often with a yeast or fungal infection
• Headaches, or tingling and numbness in the arms
• Difficulty exercising, sleeping, working, or finding clothes that fit

Size alone is not enough. Your insurance company needs to see that the weight of your breasts is causing you harm, and that it has been going on for some time.

What your insurance company will look for

A documented history

Symptoms recorded over the years carry far more weight than symptoms described for the first time at a surgical consultation. If your primary care doctor, physical therapist, chiropractor or dermatologist has noted them in your chart, your case is considerably stronger. If they have not, start now.

The treatments you have already tried

Supportive bras, anti-inflammatory medication, physical therapy, occupational therapy, chiropractic care, and creams for rashes all count. Most plans want to see that you have given these a proper trial, often over several months, before they will consider surgery. Keep a note of what you tried and when.

How much tissue will be removed

Many insurers use a calculation based on your height and weight to set the minimum amount of breast tissue that must be removed. If less than that is planned, they will usually classify the operation as a breast lift, which is cosmetic, and decline to cover it. During surgery every piece of tissue is weighed, and the pathologist weighs it again afterwards, so the figure is documented twice.

What happens at your consultation

If your benefits check confirms that we can work with your PPO plan, your consultation is free.

Dr. Li will take a full history, examine you, take detailed measurements and photographs, and document any rashes or shoulder grooving. She will then tell you honestly whether she believes your insurance is likely to approve your surgery. If she does not think it will, she will say so rather than put you through a process unlikely to succeed. You will leave with a five-to-six-page consultation note as a PDF, and you are always welcome to bring someone with you.

What if I am denied?

A denial is not necessarily the end of the road. Dr. Li can sometimes request a peer-to-peer review with your insurance company's medical director, and you have the right to appeal. If your plan excludes breast reduction altogether, your options are to change plans at open enrollment or to pay out of pocket, and we are happy to give you a quote.

Does insurance cover oncoplastic breast reduction?

An oncoplastic breast reduction is a breast reduction performed on the same day that a breast cancer patient has her tumor removed by her breast surgeon, in an operation known as a lumpectomy. The two surgeons work together, and the goal is to reshape the breast so the defect left by the cancer surgery is hidden. Instead of a dent or a distortion where the tumor was, you are left with a natural, balanced result.

This is considerably more demanding than a routine breast reduction. Dr. Li is working around the position of your tumor and the operation your cancer surgeon needs to perform, and she has to plan the reduction so the breast can be reshaped safely without compromising your cancer treatment. Not every plastic surgeon has experience with these operations, and it is a fair question to ask your plastic surgeon if they have experience in oncoplastic reduction, before you choose your surgeon. Dr. Li has more than ten years of experience with them, many performed during her time at City of Hope, one of Southern California's busiest cancer centers.

Coverage varies. Some plans approve oncoplastic reduction readily as part of your cancer treatment, while others look at it closely, and how the request is documented and presented makes a real difference. Dr. Li understands those nuances and how to put your case forward to improve your chances of approval.

Oncoplastic surgery is explained in more detail on Dr. Li's breast reconstruction page.

Does insurance cover a symmetrizing breast reduction?

A symmetrizing reduction is performed on one breast so that it matches the other, and there are two common reasons for it. Sometimes one breast simply did not develop in the same way as the other. More often, it follows cancer treatment: after a lumpectomy, and particularly after radiation, the treated breast can become smaller, firmer or higher, leaving a difference between the two that is difficult to live with.

Dr. Li performed many of these operations during her years at City of Hope, and they remain a significant part of her practice today.

If your symmetrizing surgery follows a mastectomy, federal law requires plans that cover mastectomy to also cover surgery on the other breast to achieve symmetry. California law goes further: it counts a lumpectomy as a partial mastectomy, so plans regulated by the state must also cover reconstruction and symmetry surgery after one. Some employer plans follow federal rules only. For those, coverage after a lumpectomy depends more on your individual plan, and once again, experience in presenting the request is what makes the difference.

For the surgery itself, see Dr. Li's breast reduction page, or breast reduction in Pasadena.

More on using your insurance

• How we work with your insurance, from the benefits check to appeals
• Insurance coverage for breast reconstruction

Call our office at 626.888.9728 to schedule your consultation, or request an appointment online.

The information on this page is general and is not a guarantee of coverage. Every insurance plan is different, and coverage decisions are made by your insurance company.