Breast Reduction – Why You Should Consider Not Using Insurance

Many patients are interested in having breast reduction surgery. Unfortunately, what we see time and time again is that an insurance company is going to put its best interest in front of the patients. While many patients might find that breast reduction surgery is “covered” by their insurance company, what is often not shared is the required steps for that approval. Which is often a lengthy, complicated, and frustrating process for patients and their surgeon.

Proof of medical necessity is required for approval for a breast reduction surgery for nearly all insurance companies. To prove the surgery is a medical necessity documentation of a conversative management is required. The conversative management length can vary by insurance company. It can be as low as 30 days but as high as 12 months, most common is at least 3 months. Conservative treatment is usually with one or more of the following:

• Special support garments (for example, special support bras, bras with wide straps
• NSAIDs
• Physical therapy
• Chiropractic therapy
• Other similar modalities

Some insurers also have very specific guidelines in terms of additional requirements beyond proof of medical necessity that have eliminated a patient from receiving an authorization for surgery. This has included that a person to be within 20% of their ideal body weight before approving coverage, as weight loss alone can cause the breasts to become smaller.

It has also included a minimum amount required to be removed to be covered by insurance. This definition varies by insurance carriers. For some, if the amount of breast tissue removed is less than 200 to 350 grams (7 to 12 ounces), the procedure may be considered a breast lift rather than a breast reduction and is not covered. Others require that the amount of breast tissue being removed from each breast be greater than or equal to 22% of Body Surface Area (BSA). It is not until surgery is performed can some of these details be determined. We have had several patients move forward with surgery because they received a prior authorization for the medical necessity only to be hit with a huge bill because once of the surgeon submitted their surgical report, they did not remove enough breast tissue to qualify, and the surgery was denied after the fact.

It is also not common that to meet the minimum amount of breast tissue removal requirement a surgeon is often leaving a patient with little to no breast tissue. Creating additional body image issues for the patient and the necessity to consider breast implants to create a normal, natural looking breast again.

Due to the complexity describe above we do not accept insurance for breast reduction surgeries; however, we do offer competitive cash pay rates for medical necessary breast reductions. The price varies by the complexity of each individual case, but a good range is between $8,000 to $12,000. This is the all-in price, including the physician fees, anesthesiologist and operating room fees.

We know how transformative this surgery can be for our patients and how frustrating the insurance process can make them. We are here to help patients look and feel their best in a timeline that fits their schedule, not the insurance company. We also offer payment plans that help patients fit the cost of surgery into budget over a 6 month to 12 month timeline.

If you are intersted in scheduling a consultation text us at 346-534-6907 to get scheduled.

Below is a case study of 2 patients of Heights Plastic Surgery who were seeking breast reduction surgery. The first went with Heights Plastic surgery as cash-pay, the other decided to go through another surgeon who accepted insurance.

Patient # 1 Breast Reduction Cash Pay

TOTAL COST: $10,940
TOTAL TIME TO SURGERY: Less than 45 DAYS
TOTAL TIME TO FULL RECOVERY: 3 MONTHS

Day 1
Patient decides they are ready for a breast reduction surgery.

Day 2 – 14
Patient researches and consults with 2 plastic surgeons to determine who they would like to perform their surgery.
COST: $300. Consults with 2 physicians before deciding who to move forward with. The consult fee is $150 for each

Day 15
Their plastic surgeon works at a private ASC facility and operates 5 days a week and patient could have surgery as soon as next week. Patient selects date for surgery that fits best in their schedule/life, for this patient that day is sometime “next month”.

Day 31
Patient pre-ops for surgery, picks up prescriptions
COST: $140
$75 Post-Op Garment & $65 Medications [Using Insurance] 

Day 45
Patient has surgery.
COST: $10,500
This will vary by plastic surgeon but is the “all in price”, includes physician fees, anesthesiologist, and operating room fees.

Day 59 – Day 66
Patient is cleared for light duties, generally 2 – 3 weeks after surgery

Day 87  – Day 101
Patient cleared to resume all normal activities, generally 6 – 8 weeks after surgery

Patient #2 Breast Reduction Going With Insurance

TOTAL COST: $8,545
TOTAL TIME TO SURGERY: More than 9 MONTHS
TOTAL TIME TO FULL RECOVERY: 12 MONTHS

Day 1
Patient decides they are ready for a breast reduction surgery, calls insurance company. It is a potentially covered surgery but will require clinical documentation that supports the medical necessity of this procedure. Per the insurance company this includes conservative management for at least 3 months*.

Day 4
Patient meets with PCP to discuss diagnosis of breast hypertrophy [large breast] and the conservative management plan for the back pain it is causing. It will include 3 months of:

1.Daily Ibuprofen
2. More supportive Bra
3. 10 Chiropractic visits
COST: $75 Co-Pay

Day 5 – Day 100
Patient completes 10 Chiropractic visits, follow ibuprofen regimen and purchases more supportive bra over 3 months

COST: $605
$75 for 2 Bras + $30 Ibuprofen + $50 Co-Pay x 10 for Chiropractic visits

Day 101
Patient meets with PCP to discuss how conservative management isn’t working. PCP agrees and creates a referral to a surgeon. Will print off paperwork that it can be given surgeon for submission to show conservative management was attempted and didn’t work.
COST: $75 Co-Pay

Day 102 – 116 [2 weeks]
Patient researches in-network surgeon who are accepting insurance to perform breast reduction surgery.

Day 117 – 130 [2 weeks]
Consult with 2 in-network plastic surgeons before determining the surgeon they would like to perform their surgery.
COST: $150 Co-Pay [2, $75/each]

Day 131
Surgeons office submits paper work for prior authorization to the insurance company. This can take up to 4 months.

Day 215 [12 weeks from submission]
Patient receives prior authorization from insurance company to have surgery, it took 12 weeks.

Day 216
Surgeon office verifies insurance benefits after prior authorization has been received. Plastic surgeon only operates on Thursday at the patients in-network hospital. First available is in 2 months during which the patient’s insurance new annual plan being begins, all deductibles have been reset. Patient has a deductible of $5,000 and a max out of pocket of $7,000. The patient will be responsible for $7,000. Physician requires patients to pay max out of pocket fee to pay upfront.
COST: $7,000

Day 217
Insurance company requires mammogram prior to surgery due to patient being over the age of 40.
COST: $0
Considered preventative and is covered by insurance

Day 262
Patient pre-ops for surgery, picks up prescriptions and purchases post-op garments
COST: $140
$75 Post-Op Garment + $65 Medications [Using Insurance]

Day 276
Patient has surgery. Physician hasn’t billed for services yet, upon check in at the hospital patient is required to hospital co-pay which is $500. Hospital states patient will be refunded co-pay if once billed didn’t need to collect co-pay.
COST: $500

Day 290 – 297
Patient is cleared for light duties, generally 2 – 3 weeks after surgery

Day 318- 332
Patient cleared to resume all normal activities, generally 6 – 8 weeks after surgery