How to Get Breast Reduction Surgery Covered by Your Insurance

There is a very good chance that your insurance will cover a breast reduction procedure - we can help!

a young girl with red nails lays on a bed with her legs up in the air
Melanie Shwartz
Melanie Shwartz

Cosmetic Nurse at Aesthetica Cosmetic Surgery and Laser Center in Leesburg, Virginia

Getting a medically beneficial breast reduction surgery shouldn’t be so difficult.  With that being said, our office has streamlined the process in the the last few years to make the pre-authorization process as simple for you as possible.  For the most part, you simply need to come in for a consultation and we will help you to the best of our abilities to get your medically necessary breast reduction covered by your insurance company.  

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Not too long ago, breast reduction surgery was not covered by insurance at all. It required an act of Congress for having large, heavy breasts to be acknowledged as a cause of multiple medical conditions including: spinal curvature with back and shoulder problems, rashes, a reduced ability to exercise due to the physical weight as well as psychosocial shame.

After all, insurance companies have a strong incentive not to cover breast reduction surgery. I can think of at least two reasons for that:

  1. The condition is not life threatening.
  2. The estimated percent of women who would choose to a breast reduction if it were paid for is upwards of 20 to 30%.

Insurance companies don’t want to have to pay for a procedure that 20-30% of women might actually ask for, were it offered. Fortunately, the women of America came out on top thanks to Congress. (For more information about the procedure involved with breast reductions, visit Dr. Chang’s website.)

a large breast is overlaid by an arrow pointing to where it should be corrected to go to while a small breast looks nice

This image shows the difference between a heavy, oversized breast on the left and a smaller, but appropriately proportioned breast on the right.

Check Your Insurance Policy: Does It Exclude Breast Reductions?

It is rare to have a complete breast reduction exclusion with medical insurance in the state of Virginia. Even in cases where one has existed, our office staff have occasionally been able to help patients get partial coverage for their procedures.

Document Potential Medical Problems Attributed to Large Breasts

To a large extent, your insurance carrier will not care if you have back or shoulder pain or other subjective complaints. However, you should make a list of physical problems that you can attribute to your large breasts. Some examples might include:

  • Large breasts can cause rashes.
  • Large breasts can lead to spinal curvature.
  • Large breasts can cause shoulder grooving and indentations from the weight on your bra.
  • Large breasts can actually lead to weight gain if you can’t easily exercise.
  • Large breasts can secondarily lead to type 2 diabetes due to gaining weight.
This list of problems needs to be included in your pre-authorization letter. If you are unsure of what to include, our office can help you put together a list.
 

Ariel Winter from Modern Family after her breast reduction.

Do You Have Out-Of-Network Benefits?

Your insurance network may require you to see one of their in-network plastic surgeons. The problem is that they might not necessarily be the best qualified plastic surgeons. Furthermore, you might already have a plastic surgeon that you know and trust.

Keep in mind that you can only go to a plastic surgeon of your choosing if you have a PPO form of insurance allowing out-of-network doctors.

Come In For A Consultation

If you come in for a consultation, Dr. Chang and his staff can review and advise you about everything you need to know concerning the insurance process. 

Your breast reduction consultation will include determining if we feel the procedure is medically necessary as well as providing acceptable justifications for obtaining medical insurance coverage for your breast reduction.

Obtain A Letter of Medical Necessity

We have determined that most insurance companies in Northern Virginia really only have 3 requirements for coverage:

1.  Patients need to want and accept the removal of about 400-500 grams of breast tissue per breast. (Note: 500 grams is approximately the size of a grapefruit.)

2.  Patients will be required to have their doctor write a letter of medical necessity that includes the acceptance of a 500 gram tissue removal.

3.  The preauthorization request must include a picture of the patient that can visually demonstrate her large breasts.

What does medical insurance pay for?

Patients need to understand that their medical insurance does not necessarily pay for their entire procedure.

One of the many problems with the insurance process—whether it is for breast reduction surgery or a routine medical visit—is that they do not tell you up front what they will compensate you or your physician for. 

In other words, you don’t and won’t know until AFTER your surgery whether they will be paying 10 dollars or 10 thousand dollars toward your surgery. 

They will generally pay for the anesthesia and facility fees in full. Be sure to ask your surgeon what you will be responsible for in the event that the insurance company pays less than expected.

Remember Your Deductibles!

Many patients now have extremely high deductible insurance plans.  As you should know, you will always be responsible to meet your deductibles before your actual insurance kicks in.  

What Are "Health Savings Plans"?

Many patients will benefit from their health savings plans. The rules and regulations are frequently less rigid than standard health insurance. 

Your HSA may work along with a High Deductible Insurance plan FSA (Flexible Spending Account) through your employer or your business, some of the costs not covered by health insurance may fall within the “medical necessity” guidelines for these plans. 

These savings accounts are funded from your pre-tax dollars (or deducted from taxes), so it would be like getting a discount on the surgery. Check with your plan administrator. 

Playing the Insurance Game: Getting Pre-Approval

Most insurance companies will respond within two to four weeks. Insurance companies will often deny your procedure after the first submission. 

Note that we will work on your behalf to try to get it approvedIt is a bit of a game on their point, hoping that you will drop the request after the initial application. In the event that your insurance company denies your claim in Virginia, we will resubmit the preauthorization letter with some additionally substantiated documents. We may also need to speak to their medical director.

Goals of Breast Reduction

  • Reduce the size and weight of the breast.
  • Lift the breast.
  • Lift the nipple areola area.
  • Reduce the size of the areola if necessary.
  • Improve any size asymmetries between the two breasts.

Benefits of Breast Reduction

  • Reduce the size and weight of the breast.
  • Easier ability to buy fitted clothes.
  • Ability to buy less expensive bras.
  • Ability to have better options in buying a bra.
  • Improved ability to exercise physically and pychologically.
  • Decrease unwanted attention.
  • For further information, visit Dr. Chang’s website. 

Finding the Best Breast Reduction Surgeon in Virginia

Dr. Phillip Chang is known to be one of the best breast reduction surgeons in Virginia after performing hundreds of breast reduction procedures for almost 20 years. His innovative techniques have been highlighted in national magazines and educational channels prompting patients across the country to send revision breast reduction procedures to his office in Northern Virginia outside of Washington, DC.  

Visit his office in Leesburg, Virginia in Loudoun County or fill out the contact form below for more information on how we can help you with your breast reduction surgery.

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FAQs for Breast Reduction

More answers for your breast reduction questions.  Additional information can be found on the procedure pages on our website

Macromastia, gigantomastia, mammary hyperplasia, and breast hypertrophy are all medical terms describing large breasts.  Symptomatic macromastia describes the condition where large breasts can cause pain or obstacles to everyday life.

The medical term for breast reduction is reduction mammoplasty.  This is the term that you might find on our medical cpt code for breast reduction surgery.

Breast reduction surgery and breast lift surgery are nearly identical procedures.  The major difference between the two procedures is the amount of breast tissue that is removed.  Both procedures require the same incisions depending on how much your breasts sag.  Small breasts will benefit from a donut-style incision.  Larger amounts of sag will require a lollipop-style incision.  Even larger amounts of sag requires an anchor-style incision.  See our website for a more detailed explanation.  With this in mind, breast lifts remove skin and only as much breast tissue as required.  Breast reduction surgery will remove skin and as much breast tissue weight as you dictate.

Most patients can return to work or school after about one week.  Your breast reduction scars are closed with absorbable sutures and will have completed their initial healing by that time.  Most patients will still be sore.  Most patients will feel like themselves in about 3 months.  Final visual breast reduction results in terms of shape and the breast reduction scars will not be seen for up to a year.

Breast feeding after breast reduction surgery is generally preserved.  For this, you need to know the normal statistics for breast feeding.  Statistically, about 20 percent of normal women that do not have breast reduction cannot breast feed.  20% of women after breast reduction surgery cannot breast feed.  There is no difference.