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The cost of breast reduction surgery without insurance is about $5,600 before factoring in facility fees, anesthesia, and related expenses.
Clearly, having your healthcare plan cover the expense is the preferred option. If approved, your costs with insurance could include deductibles, co-payments, and out-of-network balance billing.
If only you could be so lucky to have to pay for the deductible! But you must convince them that your physical symptoms are severe – and not for aesthetic reasons.
Most women fail the criteria for coverage. Monthly payment plan financing and careful tax planning can make the procedure more affordable.
Breast Reduction without Insurance
Sometimes, women must pay the full cost of breast reduction surgery without health insurance because their motivation is purely cosmetic rather than medical.
If your company rejects your precertification, a payment plan allows you to pay for the procedure in smaller installments. Then, the tax code could limit the amount you must borrow.
Request a personal loan (Sponsored Link) to finance your breast reduction surgery if your insurance will not cover the procedure. Adding to your debt should be a last resort. Take this step only after appealing any precertification denials, unless your reason is solely aesthetic rather than medical.
If approved by the lender, you will have granted yourself a monthly payment plan that enables you to choose a local plastic surgeon with the best reputation for success. Having money deposited directly into your checking account allows you to shop around and prioritize expertise over in-house financing.
Borrow enough money to cover the estimated costs suggested by your provider. The average price of reduction mammoplasty is $5,600, which does not include fees for anesthesia, facilities, and related expenses.
The chances of finding a surgeon that will perform a free breast reduction procedure without a contribution from insurance are slim at best. Many providers will offer a consultation at no charge but expect them to bill for any remaining services at their full retail price.
However, the tax code presents opportunities to lower the amount you must finance when you go under the knife for medical reasons – not cosmetic. Both options introduce a new gatekeeper who determines eligibility.
- Flexible Spending Accounts offer first dollar tax savings and can work like an interest-free loan from your employer. Opt to make a full contribution during the open enrollment, and schedule the procedure for the beginning of the new plan year (January is most common). The FSA plan administrator will review the claim.
- Deduct your qualifying medical expenses on Schedule A when you file your return on or before April 15. The amounts exceeding 10% of Adjusted Gross Income could lower your tax bill for people who itemize. Consult with your accountant about whether your expenses qualify and will hold up under an IRS audit.
Insurance Paying for Breast Reduction
The key to getting your health insurance plan to cover your breast reduction surgery is to demonstrate the medical necessity. Medically necessary can mean the services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms.
In other words, your condition (macromastia) must cause symptoms (pain, infection, loss of function via numbness), which you must document in advance.
Choosing a practice with medical billing expertise improves your chances that insurance will approve your plastic surgery for breast reduction. Their letter of medical necessity should address weight requirements, ICD codes, and symptoms.
- Body Mass Index (BMI) is a fraction that measures obesity levels. A BMI over 35 could indicate that you are too heavy for approval.
- International Classifications of Disease (ICD) codes communicate the symptoms you are experiencing in a language the company will understand.
- 9: 611.1 postural backaches
- 9: 724-5 upper back and neck pain
- 9: 695.89 skin fold irritation (intertrigo or dermatitis)
- 9: 782.0 ulnar nerve numbness
Cost with Insurance
The price to you, the patient, for breast reduction surgery, when insurance covers the procedure depends on the cost-sharing features built into the plan, and whether you choose a participating provider.
Every healthcare plan has cost-sharing components that determine your out-of-pocket portion of expenses.
- Annual deductible is the patient-funded amount before benefits begin
- Co-insurance is the percentage of allowed charges paid by the member
- Co-payments are fixed amounts paid by the patient after each provider visit
Many plans also have networks of providers who agree to accept a discounted fee as payment in full in exchange for patient volume. Expect a hefty balance bill if you choose an out-of-network surgeon. You will be responsible for 100% of the difference between the retail and wholesale price (discounted allowed charges).
Your health insurance may pay for breast implant removal – even when the original augmentation procedure was for cosmetic purposes only. Again, you must establish the medical reasons you need to have the devices removed.
- Cancer near the affected area
- Implant-associated anaplastic large cell lymphoma
- Extrusion through the skin
- Severe contracture causing pain
- Rupture of silicone gel-filled implants
- Cutaneous hypersensitivity-like reactions
- FDA-withdrawn textured implants
- Textured implants causing pain, lumps, or asymmetry
Every health insurance company issues hundreds of different plans, and each one will have unique rules regarding the approval criteria for breast reduction surgery. Therefore, it is impossible to learn online about how each company will respond to a precertification request.
Your best bet is to work with the billing person at your provider to clearly articulate the physical symptoms that your overly large and pendulous breasts are causing. Use the following information to sharpen the letter of medical necessity.
- Blue Cross Blue Shield (BCBS) is a national federation of affiliated companies using this trade name. BCBS is thirty-six different independently operating local organizations rather than a single entity.
- Medicaid is a federal government program administered at the local level, and each state determines the rules for services they cover on behalf of low-income families. In turn, private companies issue Medicaid-compliant policies and adjudicate claim approvals and denials.
- Medicare is a federal program for retired senior citizens and disabled individuals. Each person has up to four Medicare “Parts” that could be involved in approving or denying your case.
- A: Inpatient hospital care
- B: Medical services and supplies
- C: Advantage plans that combine parts A & B
- D: Prescription drug coverage
- Medigap supplements fill out-of-pocket costs
 Aetna Medical Clinical Policy Bulletin # 0142