When breast augmentation or reduction cases are medically necessary

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.

Surgery, rather than conservative treatment or weight loss, provides the best chance for Andrea's relief. Additionally, patients, like Andrea, who have congenital breast deformity or who have experienced breast trauma, infection, tumors or disease, may also qualify for breast augmentation or reduction when it's considered reconstructive. These patients might have Poland's Disease or cancer, breast drooping caused by dramatic weight loss due to gastric surgery, significant breast asymmetry, or have had a mastectomy.

When unsure, the AMA is encouraging third-party payers to refer to such definitions in determining what services are eligible for coverage under the plans they offer or administer, as well as leverage the expertise of IROs for any questionable cases. IROs offer a deep panel of experts that understand the definitions of cosmetic and reconstructive surgery and can help payers ensure patient treatments are medically necessary. IROs can also help doctors confirm their diagnosis by reviewing clear documentation and the high-resolution photographs of the breast area and any other areas affected.

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