Traditionally, breast augmentation and reduction surgeries are defined by health insurers as cosmetic. It's a definition that often puts patients at odds with health insurers. Payers have difficulty deciding if breast augmentation or reduction cases are medically necessary.
For example, a doctor prescribes a breast reduction for Andrea, a five-foot one-inch, 135 pound, 32-year-old female. Her plastic surgeon recommends removing 500 grams of tissue from each breast. Is this breast reduction considered medically necessary and something that is covered under her medical plan?
According to Dr. Skip Freedman, medical director at AllMed Healthcare Management, a leading Independent Review Organization (IRO), Andrea should qualify for the treatment because of the following reasons:
- For several years, she has complained of shoulder, back and neck pain, bra strap grooving and intertrigo (eczema).
- She wears a 34DD bra and attributes these symptoms to her breasts.
- She's worn support bras, taken non-steroidal anti-inflammatory drugs (NSAIDs) and has had years of chiropractic treatments without alleviating her symptoms.
- She has symptoms consistent with macromastia (excessively large breasts)
- Her doctor notes that her complaints are typical for that diagnosis.
According to the American Medical Association (AMA), when reconstructive surgery, such as breast augmentation or reduction, is performed on an abnormal structure of the body caused by disease, infection, congenital deformity, trauma or tumors, it is considered medically necessary and generally done to improve the body's function.