Can Insurance Cover Breast Reduction? Coverage and Criteria

Can Insurance Cover Breast Reduction?

The question of whether insurance can cover breast reduction surgery is one that resonates with many individuals seeking relief from physical and emotional discomfort. Breast reduction, though often perceived as a cosmetic procedure, can also be a medical necessity for some. This article explores the circumstances under which insurance might cover breast reduction surgery, shedding light on the criteria and processes involved in obtaining coverage.

Can Insurance Cover Breast Reduction?

Breast reduction surgery, also known as reduction mammaplasty, involves the removal of excess breast tissue, fat, and skin to achieve a breast size more proportionate to the body and to alleviate discomfort. While the aesthetic aspect of breast reduction is well-known, the procedure also has significant health implications, particularly for individuals experiencing chronic pain, posture problems, and other medical issues due to large breasts.

Understanding Insurance Coverage

Determining whether your insurance policy covers breast reduction surgery requires an understanding of the fine line between cosmetic and medically necessary procedures. Most insurance policies have specific criteria for covering surgeries deemed medically necessary.

Key Factors Influencing Coverage

Several factors can influence insurance coverage for breast reduction, including documented medical symptoms, the amount of tissue to be removed, and previous attempts at non-surgical treatments.

In the following sections, we will delve into the criteria for insurance coverage of breast reduction, how to present your case to insurance providers, and what steps you can take if your initial claim is denied:

  1. Criteria for Insurance Coverage of Breast Reduction
  2. Documenting Medical Necessity
  3. The Process of Obtaining Insurance Approval
  4. Handling Insurance Denials and Appeals

By understanding these aspects, individuals considering breast reduction surgery can better navigate the insurance landscape and advocate for the coverage they need.

Let’s examine the nuances of insurance coverage for breast reduction surgery, offering insights into how and when this procedure can be covered by insurance.

Criteria for Insurance Coverage of Breast Reduction

Medical Necessity

Insurance companies typically cover breast reduction surgery when it’s deemed medically necessary. This could be due to chronic back and neck pain, skin issues under the breasts, or other medical problems caused or exacerbated by large breasts.

Specific Requirements

Most insurance policies have specific criteria that must be met for coverage. This can include the minimum amount of tissue that needs to be removed or a documented history of medical issues related to breast size.

Documenting Medical Necessity

Detailed Medical Records

To prove medical necessity, you’ll need detailed records from your healthcare providers documenting your symptoms and the impact on your health. This may include records of physical therapy, chiropractic care, or dermatological treatments.

Letters from Healthcare Providers

A letter from your primary care physician or a specialist outlining the medical need for breast reduction can strengthen your case. They should explicitly link your symptoms to your breast size and recommend surgery as a solution.

The Process of Obtaining Insurance Approval

Prior Authorization

Before undergoing surgery, obtain prior authorization from your insurance company. This typically involves submitting a formal request along with all necessary medical documentation.

Consultation with a Plastic Surgeon

A consultation with a board-certified plastic surgeon is a critical step. The surgeon can provide a professional assessment and compile the medical information required for insurance approval.

Handling Insurance Denials and Appeals

Review the Denial

If your insurance claim is denied, review the reasons for denial carefully. Understanding why the claim was denied can help you address the specific issues in your appeal.

The Appeals Process

You have the right to appeal the insurance company’s decision. This process involves submitting additional documentation or clarification to counter the reasons for denial.


In conclusion, while breast reduction surgery can be covered by insurance, obtaining coverage often hinges on proving medical necessity. It requires a thorough and well-documented process, starting from detailed medical records to a comprehensive evaluation by a qualified surgeon. Understanding your insurance policy’s specific requirements and criteria is crucial in this process. For those whose quality of life is significantly impacted by their breast size, it’s worth exploring this avenue and diligently pursuing the necessary steps for insurance coverage. Remember, effective communication with your healthcare providers and insurance company, along with persistence in following the required procedures, is key to securing the coverage you need for this life-changing surgery.