Health insurance coverage can be extremely confusing — even when you’re just paying your premium month-to-month and don’t have medical bills coming in.
In this article, we will be discussing insurance as it relates to the cost of breast reduction surgery (the removal of excess skin and breast tissue to reduce the size of large breasts). Unfortunately, we cannot provide a simple answer to the question, “What does breast reduction cost with insurance?” The estimated cost of breast reduction surgery with high deductible insurance (or any type of insurance coverage, for that matter) is too challenging to provide a specific quote for.
This is simply because it varies so widely from patient to patient. Health insurance companies vary. Health insurance plans vary. And the unique situations of each patient vary. Furthermore, all plastic surgeons charge different amounts for their breast reduction procedures.
What we can provide is an overview of the most important facts to know about insurance and breast reduction surgery coverage.
Breast Reduction Cost With Insurance
Does Health Insurance Cover Breast Reduction?
Nearly 100% of the time, cosmetic surgeries are not covered by health insurance. Why? Because they are not something you need; they are something you want.
This is a topic that can be quite understandably confusing, so let’s break it down a bit.
First and foremost, all surgeries can be put into one of two categories: elective or medically necessary.
- Elective surgeries (or other medical treatment procedures) are those that a patient wants but doesn’t need.
- Medically necessary surgeries are those that a patient needs (for their health).
This is a basic definition of these terms, but even then, the question remains: “Who’s to say what a patient needs?“
And here’s where we need to talk about what “medical necessity” means.
What Does “Medical Necessity” Mean?
For some surgeries, it’s obvious. Gallbladder removal, for example, is “medically necessary” because without this surgery, a patient could develop an infection, jaundice, or even cancer. Similarly, an infected tooth must be removed right away in most cases, or a more severe and life-threatening infection could occur.
Things get foggier when we look at plastic surgery. Within the plastic surgery world, there are two types of surgery as well: reconstructive surgery and cosmetic surgery.
If you’re undergoing reconstructive or corrective surgery, this means you’re undergoing a medically necessary surgery. This type of surgery includes cleft lip and palate repair, nose surgery to repair a deviated septum, breast reconstruction after a mastectomy due to cancer, etc. All of these surgeries are needed and necessary in order to restore normal appearance and function to an individual’s life.
Cosmetic surgeries include breast augmentation that is not a reconstructive surgery but simply meant to increase the breast size for aesthetic purposes. Cosmetic surgeries also include rhinoplasty to fix a bump in the nose, liposuction to slim the waistline, a breast lift to make the breasts perkier, etc.
Some people still get confused here, however. For example, you may be a woman who’s had children and you have loose skin on your abdomen, stretch marks, and abdominal muscles that are separated due to pregnancy. You may feel that you need to get these issues fixed — especially the separated abdominal muscles. However, medical professionals and your health insurance company do not consider that surgery to be medically necessary.
Now, let’s get back to breast reduction and your health insurance company.
Is Breast Reduction Covered by Insurance?
Sometimes, but not always.
There many common reasons for breast reduction surgery. The reason we went into such detail about what “medical necessity” means is that your potential breast reduction surgery could be covered by your health insurance plan if your health insurance company deems this surgery medically necessary for you. That is, do they consider this surgery to be essential to your overall health?
If the answer is yes and if coverage for this surgery is in your plan, your insurance company may cover the procedure. They may cover all of the procedure or some of it.
Most of the time, however, you’re going to need to pay your deductible first and then the insurance company will start paying for all or some of the rest of your medical bills. So, for example if you had a $1600 deductible and your health insurance company said they would pay for 80% of the rest, you would need to pay the first $1600 of your medical bills. After that, you would pay 80% of every additional bill that came in.
From there, you’re also going to want to look at your OOP max, or out-of-pocket max. This is a sum that represents the maximum amount you should have to pay in a health plan year. Once you’ve paid this amount in health bills, you won’t have to pay anymore and your health insurance plan is going to cover 100% of the rest of the costs for that year.
FAQ: Cost of Breast Reduction Surgery With Insurance
How do you document medical need for breast reduction surgery?
You’ll need to have medical records that state your continued frustration with rashes, shoulder grooves, and other issues related to overly large breasts. Your records will need to include confirmation of medical necessity for surgery from multiple doctors.
Can I appeal if my insurance denies coverage for the breast reduction cost?
Yes, most insurance companies will outline how to appeal a denial for coverage in the rejection letter they send you concerning your reduction procedure coverage.
How much does breast reduction surgery cost 2022 with insurance?
If pain, rashes, and other problems have made your need for breast reduction surgery medically necessary, you’ll first need documentation of such struggles. Then, schedule a consultation appointment with a plastic surgeon to find out how much your surgery may cost.
At this point, you’ll be ready to consult your insurance company to see if the procedure will be covered. Patient needs, surgeon fees, and insurance companies and plans vary so much that it’s too difficult to provide a more detailed estimate of cost.
Schedule Your Breast Reduction Consultation
Dr. Schulman is an award-winning, board certified plastic surgeon with years of experience providing women with successful breast reduction surgeries. Are you wondering about breast reduction surgery before and after results? If you are thinking about breast reduction surgery for yourself or any type of breast surgery to enhance your appearance, book a consultation appointment with our office.
The dedication Dr. Schulman has in providing his many patients with optimal results, his care and attention to detail, and his kind and calming presence will tell you immediately that he’s the surgeon you want for your reduction procedure. Contact us today.