March 2020 Q & A: Does health insurance ever cover a breast procedure?
Posted February 25, 2020
There are only a few procedures covered by most insurance plans, but they typically have specific requirements that must be met prior to authorization.
A breast reduction is a procedure that reduces the size and shape of the breast to be more proportionate to a woman’s body habitus. This is done by removing breast tissue and repositioning the breasts to sit higher on the chest wall. Large breasts can cause back pain, headaches, rashes or shoulder pain, as well as breast pain with activity. These complaints will have to be documented by a primary care physician and followed with a physical exam. To have the procedure covered by the insurance company will also require that a patient has used a prescription-strength antifungal or cortisone cream to a breast rash for 3 months. Many times, an insurance company will require you to be seen by a chiropractor or a physical therapist as well. All of these exams will need to be documented and presented to the insurance company along with the surgical treatment plan. There is a Schnur Sliding Scale that is used to determine the amount of tissue to be removed in proportion to the patient’s body size or BMI. This information is presented by the surgeon to the insurance company when seeking authorization. Once authorization is complete, the surgeon will schedule your procedure.
Many women who have been diagnosed with or have a history of breast cancer should be provided with information regarding their available options when considering the reconstruction of their breasts. Regardless of any outside opinions, the decision to undergo breast reconstruction is a very personal one. Although breast reconstruction is not the choice for everyone, Dr. Antimarino believes each woman needs to have an opportunity to explore her options. Additionally, studies have proven many women who have chosen breast reconstruction experience a significant improvement in their emotional well-being and body image. Insurance companies work together with the plastic surgeon and his team to provide the appropriate authorizations for optimal care during this time.
Breast Implant Removal
In the rare occurrence of severe capsular contracture, insurance companies may cover the removal of breast implants that have developed severe thickening or hardening of the capsule. There are typically stringent guidelines that must be met prior to an insurance approval so the surgeon will communicate his observations prior to surgery as well as the results of any further testing that may be required by the insurance company.