When Does Breast Reduction Become a “Medical Necessity?”

istock_000018052378_xxxlarge-300x200“Medical necessity” or “medically necessary” are phrases developed by the insurance industry to describe a surgery that is eligible for financial coverage. Every insurance company develops its own set of criteria by which to measure an operation. If a patient fails to meet this set of criteria, they are ineligible for insurance coverage and their surgery is considered elective and cosmetic.

Breast reduction is one of the few plastic surgery procedures that can often be qualified as medically necessary. Receiving financial reimbursement for this surgery is tremendously helpful for many women that struggle with the physical burden of oversized breasts.

In many ways, the criteria to evaluate breast reduction candidates for coverage is similar among insurance companies. Here, Newport Beach cosmetic surgeon Dr. Nirav Savalia explains some of the requirements that a candidate must meet in order to qualify for medically necessary breast reduction.

Significant Back, Neck and Shoulder Pain

A struggle that is very familiar to almost every breast reduction candidate is chronic, significant pain in the back, neck and shoulders, caused by the weight and mass of big breasts. This pain can be debilitating in nature and affect a woman’s everyday life.

Skin Irritation and Rashes

Another challenge that is widespread among breast reduction candidates is painful skin irritation and rashes underneath the breasts. Some women develop regular skin infections and boils in the area where the breasts meet the torso, and may have difficulty keeping the skin clean and dry.

Posture Problem

The weight and heft of oversized breasts causes many women to walk hunched over with poor posture. Some even develop an abnormal curvature of the skin, known as kyphosis.

Insurance Coverage Considerations

First, keep in mind that plastic surgeons must provide documentation to support these criteria.

Also, when discussing medically necessary breast reductions, it is important to understand that insurers usually set forth certain terms and conditions for the operation itself. For example, the insurance company may only cover surgeries that remove a certain amount of breast tissue (e.g., 500 grams). Removing less than that would disqualify a surgery from reimbursement.

Finally, note that the information shared in this post is for general educational purposes and is not indicative of what your particular insurance company will or will not cover. Please check with your specific plan’s terms and conditions for information more tailored to you. Our office would be happy to assist by answering general questions and submitting paperwork if needed.

If you would like to speak with us regarding breast reduction and insurance coverage, please call 949-759-0980 or send us an email today.