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How to Get a Breast Reduction Covered by Insurance

Media depictions have popularized a stereotype that overly large breasts make every woman feel sexier and more feminine. As always, the reality is more complicated. Many women with oversized, heavy breasts feel weighed down and struggle with physical and emotional discomfort as a result.

Breast reduction surgery with Scott Spiro, MD, can help you look and feel better about yourself, freeing you to live a more active lifestyle and wear a broader range of clothing styles. Still, you may hesitate to choose this procedure if financial considerations hold you back. 

Fortunately, your health insurer may agree to cover the costs of your breast reduction if you struggle with issues like chronic back and shoulder pain, chafing and skin irritation, and uncomfortable bra strap indentations caused by disproportionately large, heavy breasts. However, you, Dr. Spiro, and other medical practitioners may need to prove to the insurance company that the surgery is medically necessary and not purely a cosmetic solution. Let’s explore why this is the case and what you and your medical team may need to do to get this procedure covered.

What Does Medical Insurance Typically Cover?

Health insurers pay for preventive care and medically essential treatments. They typically only cover plastic surgery performed for reconstructive purposes, such as procedures designed to restore your breasts after a mastectomy.  Not all insurance companies categorize breast reduction as medically necessary. However, this surgery can have cosmetic and practical functional benefits, so it falls into a gray area. Your insurer will consider your motivation for seeking breast reduction, including whether your oversized, heavy breasts cause discomfort or prevent you from exercising or create other problems.

What Will You and Dr. Spiro Need to Provide to the Insurer?

Each insurer uses different standards and requirements for proving when a breast reduction is a medically necessary procedure. Before approving coverage, most insurers require evidence of health problems related to large breasts, such as a history of unsuccessful treatment for skin irritation and/or back, neck, or shoulder pain related to your breasts and photographic evidence of severe bra strap indentations.

Your insurance company may ask to see medical records from your general practitioner or musculoskeletal health provider (chiropractor, physical therapist, and/or orthopedic surgeon) demonstrating that other treatments have not provided relief. For instance, you might need to prove that your problems have persisted even after receiving physical therapy or wearing a support bra.

Insurers will also want information from Dr. Spiro, including measurements of your breasts and the amount of the planned reduction to determine if it will be extensive enough to address all your concerns.

Your insurer may require details about your height and weight to show that your overly large breasts do not result from being overweight.

Convincing Your Insurer to Cover Breast Reduction

At Spiro Plastic Surgery, we’ll work with you to help you understand whether insurance coverage is a reasonable possibility in your specific case. We will submit the information on your behalf once your physician has provided your medical records.

Your first step should be to schedule a consultation with Dr. Spiro. He may ask you why you want to have smaller breasts, the problems you’ve experienced because of your breast size, what you’ve tried so far to gain relief, and what you consider a good outcome.

Based on this self-reported information and his examination, he’ll advise you on whether you’re a good candidate for breast reduction surgery and if your insurer is likely to categorize this procedure as medically necessary.

Then, you and our office can contact your insurer to explain your intention to have breast reduction surgery and to learn what they will require to approve coverage.  This is typically known as “criteria for coverage” and is what is needed for your insurance carrier to deem that your planned procedure is medically necessary.

Once you know what the insurer will need, you can begin gathering your medical records for our practice to submit for pre-authorization. If you haven’t already tried other remedies to relieve your discomfort, you might need to go through those steps first.

At Spiro Plastic Surgery, we have extensive experience in helping patients obtain insurance coverage for medical procedures. If you have questions, please call to speak with one of our billing associates. When you’ve received pre-authorization, you can schedule your surgery with full knowledge of what your insurer will cover and what you’ll be responsible for paying.

Choose a Plastic Surgeon Who Creates Beautifully Natural Results

Dr. Spiro is a board-certified plastic surgeon with nearly 30 years of experience performing breast reduction surgery in New Jersey. He is an expert in breast reduction surgery, regularly earning spots on national and New Jersey rankings of top doctors. His before-and-after gallery of breast reduction patients demonstrates his care and artistry in creating beautifully natural results.

Dr. Spiro is Horizon Omnia Tier 1 provider and is in-network with most Horizon Blue Cross and Blue Shield plans. Contact our office online or call (973) 736-5907 to schedule a consultation with Dr. Spiro.

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Graphite/Pencil Hybrid-Painting by Dr. Scott Spiro