Breast reduction: Insurance vs. self-pay

Overview: Will insurance cover the cost of a breast reduction, or will you have to pay for the procedure yourself? The answer lies in whether the surgery is deemed “medically necessary” for your health.

If you’ve been thinking about having breast reduction surgery, you may be wondering if insurance will cover the cost. It depends on whether the procedure is considered medically necessary or for cosmetic reasons only.

Whether medical or cosmetic, the procedure is very similar. However, how it’s approved, how it’s planned, and what you can control are quite different for an insurance-covered (medically necessarily) breast reduction vs. a cosmetic (self-pay) breast reduction.

Knowing these differences up front will help determine your next steps:

Insurance covered breast reduction

Insurance pays when the surgery is considered medically necessary, usually due to physical symptoms from having disproportionally large breasts, such as:

• Chronic neck, back or shoulder pain
• Shoulder grooves from bra straps
• Skin rashes or infections under breasts
• Nerve pain or numbness
• Failed conservative treatments, including physical therapy, weight loss and supportive bras

Self-pay cosmetic breast reduction

You choose the surgery primarily for:

• Appearance or body proportions
• Comfort without strict medical proof
• Desire for a specific breast size or shape
• Control over the amount of breast tissue removed, whether a small amount or no breast tissue removed (breast lift)

No insurance justification is required. 

Surgical planning differences

Insurance-paid breast reduction

The surgeon must meet specific insurance criteria which often includes:

• Minimum amount of tissue to be removed (based on body surface area charts)
• Documentation of symptoms
• Medical necessity language

The surgeon may need to remove more tissue than you want, to meet insurance approval rules. This means that your breasts may be smaller than you would like, and some degree of control will have to be relinquished to meet insurance criteria.

Self-pay cosmetic breast reduction

A cosmetic breast reduction allows for more customization and aesthetic focus. You and the surgeon decide:

• Exact size goal, including a little, a lot, or no breast tissue removed
• Shape preference
• Degree of lift
• Symmetry adjustments

Cost differences

Insurance-paid breast reduction

Pros

• Major cost covered
• You pay deductible, copay, coinsurance

Cons

• Pre-authorized process
• Possible denials or appeals
• Limited surgeon/network choice
• Less control over the amount of breast tissue that must be removed

Self-pay cosmetic breast reduction

Pros

• No approval delays
• Full control of surgeon selection
• Predictable scheduling
• Control over how much, if any, breast tissue is to be removed

Cons

• Paid entirely out of pocket

Some women may qualify medically, but choose cosmetic surgery (self –pay option) because:

• They want a smaller reduction than insurance will allow.
• They want a surgeon outside of their network.

Considering a reconstructive or aesthetic procedure? Request a consultation.