Will Insurance Cover Your Breast Reduction?

The short answer: if you meet your insurance company's criteria, yes — breast reduction is often a covered procedure. But there are several important things to understand before assuming your surgery will be paid for.

First, a clarification: all breast reductions come with a lift. You don't have to pay extra or do anything extra — the lift is part of the reduction procedure.

If you're a cancer patient having treatment and getting a reduction at the same time, this is called an oncoplastic reduction. This type is essentially always covered — even if the reduction is small.

A standard breast reduction to make the breasts smaller is more complicated from a coverage standpoint. Here's how to navigate it:

Unfortunately, some insurance plans list breast reduction as an exclusion, meaning it will never be covered regardless of medical need. Start by confirming your plan isn't one of them.

Most insurance companies use the Schnur scale to determine coverage. They take your height and weight, calculate your body surface area, and match it to a minimum weight of tissue that must be removed from each breast.

• Smaller body surface area = smaller requirement
• Larger body surface area = larger requirement

For reference, a soda can weighs about 355 grams — so if your plan requires 500 grams from each side, that's more than a soda can per breast.

Important note: Dr. Schnur himself does not want his research used this way, and the American Society of Plastic Surgeons has a statement against this method. But unfortunately, this is what insurers use.

Some insurance companies also want:

• A letter from another doctor supporting the need for surgery
• Documentation of physical therapy
• Evidence of complications from large breasts (rashes, infections)

Dr. Killeen has found that many insurance companies don't require these extras anymore — it's become more of a pure numbers game. But if you've been to physical therapy or a chiropractor, bring those notes to your consultation to include with the pre-authorization.

Some insurers have a BMI cutoff, meaning patients above a certain BMI aren't eligible for coverage. Dr. Killeen disagrees with this practice — research shows breast reductions can be performed safely with great benefit even in patients with higher BMIs — but insurance companies often don't align with the research.

Even when your procedure is approved, you'll still likely be responsible for:

• Your deductible — if it's $5,000, you pay at least that
• Coinsurance — depending on your plan
• In-network vs. out-of-network differences — in-network providers are usually cheapest, out-of-network providers cost more

Some surgeons don't participate with insurance at all. If you find a surgeon you love who doesn't work with insurance, you can:

1. Have the surgery with them
2. Get your op note and procedure codes
3. Submit the documentation to your insurance company for possible reimbursement

This can be difficult to navigate, even with help — but it's an option if you've found the right surgeon.

Dr. Killeen regularly sees comments suggesting surgeons should "just lie" to get insurance approval. Don't do this, and don't look for a surgeon who will.

How you do one thing is how you do all. A surgeon willing to commit insurance fraud is probably cutting corners elsewhere. It can also affect:

• Their board certifications
• Their ability to work with insurance companies
• Their license to practice

You want a surgeon with integrity — both in the office and the operating room.

Breast reduction is one of the most life-changing procedures in plastic surgery, and Dr. Killeen wishes every patient who wanted one could have it. If you're considering a breast reduction, schedule a consultation to find out if you meet your insurance criteria and to learn more about what the procedure involves.