Will Insurance Cover my Breast Reduction Surgery?

In order for a breast reduction to be covered by your insurance, the insurance company must deem it to be “medically necessary.” This definition, however, varies from one insurance company to another and therefore is one of the most challenging procedures to get health insurance companies to cover. Our billing team at Ponte Vedra Plastic Surgery has years of experience navigating this challenge and is available to assist you.

What does Medically Necessary mean?

Most insurance companies require documentation that shows conservative measures have failed to relieve your back pain and discomfort. Conservative measure may include supportive undergarments, over-the-counter creams or medications for rashes, prescription pain medications, and even physical therapy. The most efficient way to assemble this information is to ask your provider, usually a Primary Care Physician, OB/GYN, or chiropractor, for a letter of medical necessity that outlines your symptoms, duration of tried and failed therapies, and his or her recommendation for breast reduction surgery.

What information will I need to provide?

When you call to schedule your consultation, we ask for your insurance information as well as current height and weight. Most insurance companies use a scale, sometimes referred to as the Schnurr scale, which uses your height and weight to determine the amount of breast tissue that needs to be removed for the surgery to be considered medically necessary. We will provide this information to your surgeon before your appointment along with the specific guidelines for your insurance. With that information in hand, your surgeon will perform an examination and be able to determine if sufficient breast tissue can be removed for insurance purposes and whether doing so will render the result you wish to achieve.

How long will it take to get a determination of coverage?

At your consultation, we take photographs which we will send as part of a Precertification/Pre-Determination request. Some insurance companies can take 4-6 weeks to complete this review so be patient and know that our team is following your request and dealing with the insurance company on your behalf. Once your surgery has been approved, you will get a phone call from our team to discuss what your patient responsibility will be. Since we bill for the surgeons and the Ambulatory Surgery Center, this helps to ensure no surprise bills after your surgery.


Authored by:  Nicole Jones, CPC - Revenue Cycle Manager

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