What to Know About Breast Surgery and Insurance

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What to Know About Breast Surgery and  Insurance featured image
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Breast surgery isn’t typically a decision someone makes on a whim, and in fact, plastic surgeons discourage that. The main reason is that breast augmentation is a major surgery that can impact a person both physically and mentally, and therefore should be well thought-out, but also because it’s not generally covered by insurance. Here, leading plastic surgeons explain which breast procedures are covered and which ones aren’t, so you can be prepared before your consultation.

Cosmetic Breast Surgery Is Not Covered

Chicago plastic surgeon Michael Horn, MD says cosmetic breast surgery such as breast augmentation with breast implants or breast lifts, are not covered by insurance, and therefore the patient is responsible for the cost. “Before scheduling a plastic surgery consultation, you should always find out beforehand if the doctor accepts insurance as payment for the type of breast surgery you are interested in, keeping in mind that cosmetic breast surgery is not covered by insurance,” adds Tucson, AZ plastic surgeon Raman C. Mahabir, MD.

Breast Reduction Surgery Might Be Covered

However, Pasadena, CA plastic surgeon Lily Lee, MD says breast reduction is one of the few breast surgeries (aside from reconstruction; more on that below) that is covered. “What is covered is dependent on your insurance policy, and most insurance companies will publish their policy criteria online. When determining if a patient is covered, they want to know that the patient has exhausted all nonsurgical options first, such as physical therapy, weight loss, rash management, etc. I tell patients seeking a breast reduction covered by insurance that the insurance company has a minimum resection weight requirement, which is calculated based on their Body Surface Area (BSA). How much is resected is not determined by me, the surgeon. In my practice, we will calculate that weight and I will give the potential patient a breast implant with similar weight to hold. I ask them, are you OK losing this much from each breast? If so, then we have a good insurance candidate.” 

Breast Reconstruction Surgery Is Covered

“Insurance typically covers two categories of breast surgery: The first is breast reconstruction surgery after breast cancer, and the second is breast reduction surgery in women who are medically symptomatic from their excessively large breast volume,” explains Dr. Mahabir.

According to information published in The Breast Reconstruction Guidebook, which is also provided on Breastcancer.org, “breast reconstruction procedures should be covered by your health insurance plan, whether they are done right away, soon after mastectomy/lumpectomy, or many years later. This includes procedures that may be needed over time to refine the reconstructed breast and/or to create symmetry (balance) between the two breasts.

The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state. Government- and church-sponsored plans are not necessarily required to cover reconstruction, so you may need to check with your plan administrator. Even if you’re covered, it’s still possible to run into problems, especially in certain situations: For example, maybe you’ve chosen a newer type of reconstructive procedure, you’re having surgery to create a more balanced appearance, or you need a complete correction of a past reconstruction. Coverage also can be an issue if you want to use a plastic surgeon who is outside your health insurance plan’s network. It’s always best to communicate with your health insurance provider up front and check on what exactly is covered so you can avoid the work of trying to get payment later.”

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