Does Insurance Cover Breast Augmentation?
Posted July 15, 2024 in Breast Procedures
Breast augmentation is one of the most popular cosmetic surgeries performed each year. However, for some, the cost of breast augmentation can be something that prevents them from undergoing the procedure. In this blog, we’ll discuss whether insurance covers breast augmentation, the requirements for insurance coverage, and the payment options if your insurance does not cover your breast augmentation procedure. Please note that insurance coverage can vary significantly depending on your specific policy and provider, so it’s always best to check with your insurance company for the most accurate information.
Reasons to Undergo Breast Augmentation
Breast augmentation patients generally fall into two categories: those seeking to enhance their breasts to boost their confidence in their appearance and those seeking breast reconstruction after surgery or to address a defect in their breasts.
For those who wish to undergo breast augmentation for purely aesthetic reasons, insurance will probably not cover the procedure. It is typically considered an elective surgery, and most insurance policies don’t cover those.
A woman’s breasts are often an integral part of her identity, making her feel feminine and whole. When congenital deformities, surgery, or injury leave your breasts deformed, or you’ve had them removed altogether, it can have a profound impact on your emotional well-being and sense of self. Breast augmentation can restore the shape and appearance of the breasts after cancer, surgery, or due to physical deformities, providing a much-needed emotional boost.
Most insurance companies will cover breast augmentation when deemed “medically necessary,” but what criteria must be met? Some reasons include:
- Breast reconstruction after a mastectomy or lumpectomy
- Congenital deformities, such as tuberous breasts, breast asymmetry, Poland syndrome (underdeveloped chest muscles and breast tissue), and amastia (no development of the breast)
- Injury or trauma to the breasts requiring reconstruction
If you suffer from any of the above conditions, it is much more likely that insurance will cover your breast augmentation.
How Do I Find Out if My Insurance Covers Breast Augmentation?
Many health insurance providers differ, allowing and disallowing different procedures. The first step to determining your eligibility for coverage is to read through your policy to see if it provides specific information about breast augmentation. Some insurance policies that may cover breast augmentation include those that cater to specific medical conditions or those that offer comprehensive cosmetic surgery coverage.
If your insurance does cover breast augmentation, you’ll need to understand the limits and exclusions associated with the policy. Have you met your yearly deductible? Is there a cap on how much of the total surgery they’ll cover? Is your coverage limited to the hospital fees, anesthesia fees, and prescriptions but excludes the surgeon’s fees? These are all vital things to know before undergoing your surgery, as you don’t want to be unpleasantly surprised when your bill arrives.
If you have questions or the specifics of your insurance policy coverage need clarification (as insurance jargon can be confusing), call your insurance provider and speak with a representative who can answer your questions. Understanding your insurance policy and its benefits and limitations is crucial and can make the entire process easier in the long run, empowering you to make informed decisions about your health.
Obtaining Insurance Coverage For Breast Augmentation
If you feel that your breast augmentation surgery is medically necessary, next comes the tasks associated with securing coverage for your procedure.
Surgical Consultation
After you’ve reviewed your insurance policy and determined that you may be a candidate for coverage, you should schedule a consultation with a board-certified plastic surgeon who is highly skilled and experienced in breast augmentation and reconstruction. During your appointment, your surgeon will listen to your concerns and examine you to assess whether or not your breast augmentation falls into the category of being “medically necessary.” If they agree you meet the standard criteria, they can help you with pre-authorization and other documentation your insurance company requires to secure coverage.
Pre-Authorization
Whether for breast augmentation or other procedures, many insurance companies require prior approval before you undergo surgery. Getting pre-authorization is essential because your insurance company can deny your claim without it. Pre-authorization paperwork often includes, but is not limited to, the following:
- Written confirmation from your surgeon that your breast augmentation is indeed medically necessary
- Medical records documenting your condition
- Relevant diagnostic tests
Your surgeon and their team should be familiar with submitting pre-authorization requests and can help guide you through the process.
Submitting Your Claim
After you have completed the above steps and received pre-authorization for your breast augmentation, you can proceed with your surgery. Your surgeon will submit a claim to your insurance company along with all of the necessary supporting paperwork.
If everything goes according to plan, your insurance claim will be approved, and your breast augmentation will be paid for. Congratulations!
However, in some cases, your claim may come back to you as denied, even though you followed the policy to the letter. Don’t let this discourage you. It doesn’t mean you’re on the hook for payment; it likely means the company just needs more information or documentation to complete the claim. Your surgeon can help you appeal the denial, providing the necessary paperwork. The appeal process typically involves submitting additional documentation or a letter of medical necessity. Be thorough and persistent, and don’t let the insurance company intimidate you into giving up too soon.
Learn More About Breast Augmentation in Beverly Hills, CA
Whether you wish to enhance your breasts to boost your self-esteem, restore your curves, or address a medical issue, breast augmentation can help. Dr. Josef Hadeed is a board-certified plastic surgeon dedicated to providing his breast augmentation patients with the support they need and the results they desire. To schedule a consultation to learn more about breast augmentation in Beverly Hills, including whether your procedure may be eligible for insurance coverage, call our office today at (310) 970-2940 or complete the online contact form.
