Does Health Insurance Cover Breast Reduction Surgery?

Extremely large breasts or macromastia can cause long-lasting health problems. In the United States, over 80,000 breast reductions occurred in 2021 according to the Aesthetic Society, a 49% increase from the previous year. Insurance companies typically consider reduction mammoplasty (breast reduction) a cosmetic and elective procedure. But, under certain conditions it may become a medically necessary procedure. If you qualify, health insurance companies do cover this specific surgery’s costs under certain medical requirements.

Reasons breast reduction is medically necessary

A medical professional will have to determine that the surgery is medically necessary. Moreover, the doctor must also make sure you have tried nonsurgical means to treat the chronic health conditions of macromastia. 

If you have health insurance, your provider should cover a reduction mammoplasty procedure to resolve a condition that causes:

• back or neck pain
• skin irritation
• skeletal deformities
• difficulty breathing
• or other chronic health symptoms

How to make sure your insurance provider will cover a breast reduction

There are several steps to qualify for breast reduction surgery coverage. Get ready to spend some time with paperwork and providers to prove the surgery is a medical need. Follow these steps to determine whether this type of surgery is an appropriate treatment for your condition and whether your health plan will cover it:

• Ask for medical documentation from a physician confirming that you have a medical condition that makes breast size a contributing factor in how you feel physically and emotionally on a daily basis (for example: back pain due to large breasts or breathing). Be prepared to provide this documentation when filing claims with the insurance company.
• Find out what standard of proof must be met before they consider paying for the procedure — this may require multiple treatments before they approve breast reduction surgery as reasonable and necessary treatment (for example: weight loss/weight gain).

When you’re talking to your insurance provider about breast reduction surgery, you need to prepare beforehand, and understand the rules of your plan. If you have any questions or concerns about whether or not your health insurance will cover your surgery, talk to your friendly licensed agent at Healthedly to find the right plan today. Or, call 855-522-2201 for more information.