Breast reduction surgery carries the controversy of whether it is ethical for insurance companies to deny women this procedure just because it is considered cosmetic surgery. More often than not, patients seeking breast reduction surgeries are looking for relief from the constant back pain, neck pain, and other muscle strains suffered due to their excess weight.
However, insurance companies rarely cover these procedures. Fortunately, there is a loophole. The insurer needs specific proof from the patient to deem the procedure legit and get insurance coverage.
For example, your doctor might ask for a letter of authorization from your insurer to carry forward with the protocol before the surgery. You may also have to submit a few photographs and health-related medical documents supporting your claims. After your insurer authorizes the claims, your doctor can start the procedure.
In this article, we will look at different ways to get a breast reduction covered by insurance.
What Is Breast Reduction?
Reduction mammaplasty or breast reduction surgery is a standard procedure for a woman who wants to reduce the size of their breasts. This procedure is done for both cosmetic and well as health purposes. A lot of physical symptoms come with enlarged breasts, which can be a cause of concern for some women.
Apart from just making the cup size of the breasts smaller, it also reduces back, neck, and shoulder pain for many women, a significant reason why women undergo this surgery.
Despite the psychological and physical plus points that this surgery brings for many women, insurance companies often deny insurance coverage for such procedures, deeming it to be an unnecessary cosmetic procedure.
What Is The Cost Of Breast Reduction Surgery?
According to the American Society of Plastic Surgeons, breast reduction surgery costs about $5913 on average. However, this is exclusive of the additional costs incurred during the process, including the operating room facilities charges and the anesthesiologist’s fees.
Many factors affect the total price of breast reduction surgery.
Like any other procedure, it largely depends on the following:
- The surgeon’s training, experience, and reputation
- Extra examination procedural fees
- Medication prescription
- The anesthesiologist’s fees
- The geographic location of the clinic
- Type of breast reduction surgery procedure used
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How To Get Breast Reductions Covered By Insurance?
To get pre-authorized for a breast reduction surgery so that your insurance company covers your charges, you need to fulfill two fundamental goals:
First, you need to have a legitimate argument on why breast reduction surgery is necessary for you. In other words, it should have some medical background to lean on so that the company can write it off as a severe medical concern that can endanger your welfare.
This means that the label of cosmetic surgery, usually tagged on breast reduction surgery, should change to medical reconstructive surgery.
The insurer is looking for proof that this “medical need” is hampering your life in some way, such as back pain, neck pain, etc., which are the most common symptoms women complain about when they have huge breasts.
Secondly, you should also prove to the insurer that you have undertaken other conservative therapies that have proven to be in vain.
This means that the alternative options you tested as a possible solution for your problem did not work, so you need to get breast reduction surgery to rid of the problem at hand.
Conservative therapies include seeing a chiropractor for back and neck issues and physical therapy for pain and discomfort. It also includes the use of support and special bras designed to help with the weight of the breasts.
Before anything, go through your existing health insurance policy to see if they cover any cosmetic procedures. If you’re lucky, you might find that some insurance companies provide help for these problems and cover your costs.
Learn about your right to insurance claims so that you stay on top of your game always.
Common Reasons For Insurance Denial For Breast Reduction Coverage:
While it is evident that many health insurance policy providers don’t include any form of cosmetic surgery in the mix of medical surgeries, you can appeal for coverage with the correct arguments.
For instance, if you are experiencing health issues due to your condition, you can claim coverage for breast reduction surgery which will unburden you of the problem. However, it takes much more than just appealing to the insurer for coverage.
There are many cases where the preauthorization was not approved, and the company did not insure the surgery. In such cases, you will have to shell out money from your pocket to pay for the surgery.
So what are the reasons behind the denial of these claims?
It’s safe to say that insurance companies have stringent rules about the differentiation between medical and cosmetic surgeries. So when you appeal to authorize your insurance coverage claim, it needs to be solid.
Unfortunately, many people fail to make the correct arguments for approval. Here are some of the common reasons why you might get denied:
- Claiming contract exclusions
- Dealing with out-of-network physicians when the company tries to get approval
- Other more frustrating factors like discomfort and personal preferences
- Incomplete or improper documentation
- Sending proposals for the removal of little tissues doesn’t appeal to the insurers as a big problem that requires medical help.
- Not meeting the criteria set by the insurer. This can include conservative therapies, which most policies state in their documents. For example, if your main issue is muscle pain, the policy might state that you need to have had at least 6 months of treatment before coming to them with the claim. Failure to reach this criterion might put your claim in the deny pile.
Apart from these issues, patients face another big problem is the Schnur Sliding Scale policy, wherein the insurer uses this tool to calculate the patient’s measurements, such as height and weight, to determine the body surface area.
This gives them an estimate of how much tissue must be removed from their body to be deemed a medically significant procedure.
For insurance purposes, even breast reduction surgery is considered a cosmetic surgery typically not covered by the companies. But certain insurance policy agencies offer coverage for cosmetic procedures like breast reduction surgery under certain conditions.
But remember that even if your insurer agrees to pay for the surgery, they probably will not cover the total charges incurred but only a partial amount. You will have to pay the remainder from your pocket in such a case.
You can also learn in-depth about The Importance of Having a Life Insurance Policy so you can insure every part of your life.