What Is a Breast Lift (Mastopexy)?
A breast lift, also known as mastopexy, is a surgical procedure that raises and firms the breasts. This is done by removing extra skin and tightening the surrounding tissue. The goal is to restore a more youthful and uplifted breast shape.
Over time, factors like aging, pregnancy, weight changes, and gravity can cause breasts to sag. A breast lift can restore confidence and comfort. However, many wonder: does insurance cover it?
Cosmetic vs. Reconstructive Surgery: Why It Matters for Insurance
This is one of the most important things to understand. Insurance companies often see breast lifts as cosmetic, which means they are done for appearance rather than health. Cosmetic surgeries are usually not covered.
But in some cases, a breast lift can be seen as reconstructive. If the sagging causes physical problems like chronic rashes, back pain, or shoulder grooving, and other treatments haven’t helped, then a lift might be considered medically necessary. That’s the key to getting insurance coverage.
Typical Insurance Criteria for Breast-Lift Approval
To get a breast lift covered by insurance, you must show it is medically needed. Here are common things insurers look for:
Documented Symptoms & Functional Impairment
You need medical records that prove your breast sagging causes physical problems. These may include:
- Rashes or skin infections under the breasts (called intertrigo)
- Neck, back, or shoulder pain
- Shoulder grooves from bra straps
- Limited physical activity
Photos and doctor notes are often required.
Medical Necessity Letter & Surgeon Notes
Your plastic surgeon must write a letter explaining why the breast lift is necessary for your health. This letter usually includes:
- A full history of your symptoms
- Evidence of failed treatments (like creams, powders, support bras)
- Clinical examination findings
- Diagnosis codes (ICD-10)
These documents help prove your case to the insurance company.
Insurance Codes & Billing: CPT 19316, ICD-10, and Beyond
Knowing the right codes can help. Most breast lifts are billed under:
- CPT Code 19316: Mastopexy (breast lift)
- ICD-10 Codes: Depends on diagnosis; common codes include L30.4 (intertrigo) or M54.2 (cervicalgia)
These codes must match what your surgeon documents. If you’re combining procedures (like reduction or augmentation), extra codes will be used.
Curious about medical expenses? Learn more about how much is an urgent care visit without insurance.
Step-by-Step Pre-Authorization Process
Here’s how you can boost your chance of approval:
- Step 1: Visit your primary doctor and explain your symptoms
- Step 2: Get referred to a board-certified plastic surgeon
- Step 3: Gather medical documentation (photos, notes, symptom records)
- Step 4: Your surgeon submits the prior authorization request
- Step 5: The insurance company reviews your case
Approval may take a few weeks. If denied, don’t panic—you can appeal.
How to Appeal a Denial Successfully
If your request is denied, stay positive. Many patients win approval after appeal. Here’s what helps:
- Ask for a written reason for denial
- Have your surgeon revise the medical necessity letter
- Include updated medical records or stronger evidence
- Consider a peer-to-peer review (your surgeon speaks directly to the insurance doctor)
Persistence often pays off.
Real-World Examples: Coverage Policies From Aetna, Blue Cross, Cigna
Every insurer has their own rules, but here are common standards:
- Aetna: Covers mastopexy when there’s proof of chronic rashes and failed treatments
- Blue Cross Blue Shield: May require photos and a 6-month history of issues
- Cigna: Often denies cosmetic lifts, but allows cases with skin breakdown or pain
Check your policy or call a rep to learn your plan’s details.
Out-of-Pocket Cost of a Breast Lift Without Insurance (2025 Prices)
If insurance won’t cover your lift, here’s what to expect:
- National average cost: $5,500 to $9,000
- Includes surgeon fee, anesthesia, facility fee, follow-up visits
Prices vary by location, surgeon experience, and whether other procedures are added (like implants).
Ever wondered what role does math play in the insurance industry? Discover how calculations impact coverage decisions in this guide.
Financing & Alternative Payment Options
If you’re paying yourself, don’t worry—many practices offer help:
- CareCredit: Medical credit card with 0% interest options
- In-house payment plans: Many clinics offer flexible financing
- Health Savings Accounts (HSAs): May cover procedures deemed partially necessary
Always ask about your options during your consultation.
Post-Surgery Follow-Up: What Insurance Will & Won’t Pay For
Insurance usually won’t cover follow-ups for cosmetic surgery. But if your lift was approved as medically necessary, it may cover:
- Follow-up visits
- Wound care supplies
- Treatment for post-op complications
Always clarify this with your provider.
Key Takeaways & Decision Checklist
- Insurance rarely covers cosmetic breast lifts
- Medical necessity must be proven
- Documentation is key: symptoms, failed treatments, photos
- CPT Code 19316 is the billing code for mastopexy
- You can appeal a denial with better documentation
Decision Checklist
- ☑ Do I have physical symptoms caused by breast sagging?
- ☑ Have I tried other treatments without success?
- ☑ Can my doctor document the need for surgery?
- ☑ Am I willing to go through the pre-authorization process?
- ☑ If not approved, can I afford to pay or finance the surgery?
FAQs About Does Insurance Cover Breast Lift
Does insurance ever cover a breast lift on its own?
Yes, but only when it’s proven to be medically necessary due to symptoms like rashes or pain that other treatments haven’t resolved.
What documentation proves medical necessity for a mastopexy?
Photos, medical notes, proof of failed treatments, and a letter from a surgeon explaining the need for the procedure all help.
Which CPT and ICD-10 codes are used when billing a breast lift?
The primary CPT code is 19316. ICD-10 codes vary but often include L30.4 (intertrigo) or M54.2 (neck pain).
How long does pre-authorization for a breast lift usually take?
Anywhere from 1 to 6 weeks, depending on your insurer and the strength of your documentation.
What can I do if my insurer denies breast-lift coverage?
You can appeal. Ask why it was denied, provide stronger medical evidence, and request a peer-to-peer review if needed.
