Introduction
Are you contemplating a breast lift and curious if your insurance plan covers the costs? You’ve got company. Lots of prospective breast lift patients (or mastopexy patients) wonder the same thing—and the response is not as clear as a simple “yes” or “no”.
Your presenting reason for the procedure (also called mastopexy), your insurance company’s criteria, and the documentation you are able to support it with heavily influences the insurance coverage for breast lifts. In this article, we will explain how insurance companies perceive breast lifts and in what circumstances they may cover the costs. Most critically, we share what you can do to enhance your chances of approval.
What is a Breast Lift?
Definition of Mastopexy
A breast lift, or mastopexy, is a surgical procedure that elevates and reshapes sagging breasts by removing excess skin and tightening the underlying supporting tissue. It can improve breast contour and restore a firmer and more youthful breast shape.
Reasons People Get a Breast Lift
Some individuals choose to undergo a mastopexy for purely aesthetic reasons, including reshaping following pregnancy, weight loss, or aging. Some individuals may also suffer from medical problems such as chronic skin irritations or even back pain. With this information, we hope you to understand that the reason you seek a breast lift can significantly determine how your insurance will assist you.
Is a Breast Lift Considered Cosmetic Surgery?
Cosmetic Surgeons vs. Health Practitioners
To insurance companies, all possible procedures fall neatly into two very distinct categories:
- Cosmetic: This covers any procedure done purely for aesthetic value and will not be reimbursed.
- Medical: This covers any procedure done to fix an issue and improves the bodily function, partially reimbursed.
Focused Clinic Classification of Breast Lift Surgery
Usually, the procedure of a breast lift is classified under cosmetic. This means it is not reimbursed. Nevertheless, there is an exception to this rule where a practitioner is able to demonstrate that the procedure is needed for their health and not just for vanity.
When Does Insurance Cover A Breast Lift?
Health Problems that Justify
These sorts of treatments are rarely reimburse, however, insurance companies may cover a breast lift when it is considered a health issue. Some common qualifying reasons are:
Chronic Back and Neck Pain Caused By Large, Droopy Breasts
In the case of large sagging breasts that develop chronic neck and back pain, coverage may be approved when the condition is resistant to non-surgical management.
Skin Problems Associated With The Lift
Certain individuals are known to suffer from debilitating rashes or infections of the skin fold under the breast. In the event that this is recurrent and chronic, it may warrant a breast lift.
Breast Reconstruction After A Mastectomy
In the United States, women who have undergone breast cancer surgery are oftentimes eligible for breast reconstructive surgery, which may also include a breast lift to make it symmetrical to the natural breast.
Building the Case for Medical Justification
Your physician will have to submit your medical records, relevant photographs, and demonstrate that you have undergone treatment (such as physical therapy or medications) before the surgery to substantiate your claim.
Common Reasons Insurance Providers Refuse to Authorize Surgery
Claims Lacking Appearance-Altering Surgery Justification
Services that are only focused on enhancing the aesthetics of the surgery, for instance, the “perking up” of breasts after a woman has gone through childbirth, are considered to be elective procedures by insurance providers.
Claims Lacking Medical Justification
Having insurance coverage for seeking medical attention will be impossible when there are no accompanying documents to certify the medical condition.
Process For Confirming Insurance Coverage for Breast Lift
Check the Insurance Policy
Search for the terms “cosmetic surgery,” “reconstructive surgery,” and “medical necessity” in the insurance plan documents.
Consult Your Medical Practitioner
Your insurance policy may be verified by a board-certified plastic surgeon who will assess your condition to determine its eligibility for coverage.
Submit A Pre-Authorization Request
Your surgeon presents your case to your insurance for assessment before the actual surgery is done.
Breast Lift Surgery Costs that are Not Covered
U.S. Estimated Costs
The American Society of Plastic Surgeons states that a breast lift costs between $5,000 and $8,000. These costs do not include accompanying fees.
Additional Fees
- Anesthesia: $500−$1,000
- Surgical Facility Charges: $1,000−$2,000
- After Surgery Care: $200−$500
Other Ways to Finance
Installment Payments
A lot of surgeons allow you to pay in monthly installments, which makes surgery financially easier.
Credit Cards for Medical Expenses
Pay for procedures with low or no interest during a defined timeframe with cards like CareCredit.
HSAs or FSAs
These accounts allow you to pay with pre-tax dollars, assuming the procedure is deemed medically necessary.
Ways to Improve Your Chances for Coverage
Write a Medical Justification
Write a report with a detailed medical history, treatment records, and daily life impacts to document the medical issue.
Documentation
Photographic evidence of the sagging skin and doctor’s notes documenting the skin irritation can support the claim.
Note-the Functional Restrictions
Tell how the sagging breasts impacts your daily activities such as posture, stationary work, or exercises.
Breast Lift vs. Breast Reduction Insurance Coverage
Why Reduction is Covered More Often
Breast reductions are commonly accepted because the procedure usually alleviates the medical issues caused by large breasts.
Main Differences Relevant To Insurance Evaluations
In a lift, the main focus is the skin and the position of the nipple, which makes the case for medical necessity harder to prove.
Practical Examples of Approvals and Denials
Case Study: Approved for Medical Reasons
A joint report from the plastic and dermatology professionals allowed her to overcome the denial after 38 years of suffering from persistent skin irritation and shoulder pain.
Case Study: Denied for Cosmetic Reasons
This denial is even more interesting. An insured 29 year old female after 2 children sought a breast lift. Documented slight back pain attributed to the lift was not convincing enough post a denial.
Last Suggestions prior to Taking Action
Discuss With a Surgeon and Insurance Specialist
Seek out professionals from opposite ends of the spectrum prior to committing a date for the surgery.
Always Document Agreements
Always ensure that the insurance company’s payment acceptance documents are properly filed to safeguard against additional charges post procedure.
Conclusion
Most breast lift surgeries are deemed cosmetic procedures and therefore not reimbursed by insurances. However, there are some exceptions regarding covered breast lifts, especially where there is a medical necessity. It is advisable to prepare a detailed account of your symptoms, cooperate with your physician, and follow your insurance’s outlined procedure for pre-approval submission to have the best possibility for coverage. And remember, even when insurance does not pay, there are financing options to make the procedure more accessible.
If you’re asking does insurance cover breast lift, you might also be curious about coverage for other procedures like does insurance cover rhinoplasty. And for non-medical concerns, it’s helpful to know does liability insurance cover theft as well.
FAQs About Cover Breast Lift
Is a breast lift ever fully covered by insurance?
Yes, a breast lift can be covered under insurance, but only if it is clinically justified such as needing the procedure due to chronic aches, skin rashes, or post-mastectomy reconstructive surgery.
Can I combine a breast lift with other procedures and still get coverage?
Coverage is possible if the breast lift is paired with a breast reduction performed under a medically necessary surgery.
What type of doctor should I see first for insurance approval?
Initiate the process with your primary care physician or a family doctor/dermatologist for the initial medical documentation, and then a board-certified plastic surgeon for the claims submission.
Does Medicare or Medicaid cover breast lifts?
Coverage is rare and is usually hard to obtain, even with a lot of documented medical necessity, similar to private insurance.
How long does it take to get insurance approval?
Insurance review periods can take anywhere from 2 weeks to several months, depending on the review procedure of the insurer.
