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Is a breast reduction considered medically necessary?

Macromastia (large breasts) can cause medical issues such as back pain, neck pain, rashes in the skin folds. If those symptoms are present, a breast reduction is considered medically necessary by some, if not most, health plans. There are a lot of published studies showing relief of back pain and neck pain following a sizable breast reduction.

Does insurance cover breast reductions?

Each insurance company has their own coverage policies. We have seen some insurances in the Washington DC area and Maryland areas that simply exclude any coverage on breast reductions, but the vast majority will consider covering a breast reduction if certain criteria are met. These criteria may vary. The best thing is to call the insurance company and ask them to send you their coverage criteria for breast reduction.

Does insurance cover breast lifts?

Not unless a reduction is being covered. Patients that simply want a breast lift without a reduction are typically not covered as this is considered by most insurance companies to be cosmetic.

Typical Criteria on Coverage

  • Symptoms of back pain, neck pain, shoulder grooving, or rashes
  • Attempts at weight loss
  • Failure of conservative pain, and or stress management that has been attempted for an extended amount of time (typically at least six months to a year). This can be medications, physical therapy, chiropractic care, etc
  • Anticipated reduction of at least 500 grams of breast tissue from each breast

What do I have to do next?

If you are having symptoms from macromastia and would like to explore your options, schedule an appointment online or give as a call.

We don’t participate with Medicaid or Medicare. We do participate with some private plans and we do accept most PPO plans. Make sure you get your coverage criteria sent to you by your insurance company before your consultation. And during dialogue with your insurance we recommend that you have, and provide supporting documentation if you have had conservative therapy. And then we will be happy to assist you in making your breasts smaller.

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