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Insurance Covers Reduction Breast New Jersey Plastic Surgery

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What is Breast Reduction Surgery

Breast reduction, or reduction mammaplasty, is the surgical removal of excess breast tissue, fat and skin to reduce the size of the breasts. Many people get breast reduction for cosmetic reasons to achieve a more proportional body shape, but there are medical conditions that require breast reduction for health reasons. In these cases insurance may cover the procedure. The breast reduction cost can vary based on factors such as the type of procedure, the surgeon's experience, and additional costs like anesthesia and medications. This article will look at what breast reduction is covered by insurance and who is eligible.

Medical Conditions That Require Breast Reduction

Large breasts can cause a multitude of medical problems that affect daily life. These problems make breast reduction medically necessary and therefore eligible for insurance coverage. Some of the conditions that may require a medically necessary breast reduction are:

  • Macromastia
  • Gigantomastia
  • Gynecomastia
  • Chest masculinization
  • Breast cancer

Chronic Pain

Large breasts can cause chronic pain in many areas of the body including:

Back Pain

The weight of large breasts can strain the upper and lower back causing chronic pain and discomfort.

Neck Pain

The constant pull of heavy breasts can cause neck strain and tension headaches.

Shoulder Pain

The weight can cause grooves in the shoulders from bra straps contributing to shoulder pain and even nerve compression.

Skin Irritation and Rashes

Excess breast tissue can cause skin problems such as:


A rash that occurs in the skin folds beneath the breasts often leading to fungal or bacterial infections.


Constant friction between the skin and bra can cause painful chafing and sores.

Skin Infections

Moisture trapped under the breasts can lead to persistent skin infections and irritation.

Posture Problems

The weight of large breasts can cause posture problems including:

Spinal Deformities

Over time poor posture can contribute to spinal issues such as kyphosis (curvature of the upper spine).

Musculoskeletal Problems

Poor posture can also lead to musculoskeletal problems affecting overall body alignment and function.

Physical Activities

Large breasts can make physical activities difficult to do and can’t be exercised. This can lead to:

  • Reduced Mobility: The size and weight of the breasts can limit the range of motion and overall mobility.
  • Exercise Intolerance: Discomfort and pain during physical activities can discourage exercise and overall health and fitness.

Insurance Coverage

For health insurance to cover breast reduction surgery the following criteria must be met. These can vary between insurance providers but generally include:

Health insurance plans often require specific documentation to prove the medical necessity of the surgery. This includes detailed medical records, a history of chronic health symptoms, and a recommendation from a healthcare provider.

Medical Necessity Documentation

Insurance companies need thorough documentation to prove medical necessity of the procedure. This documentation may include:

  • Medical History: A detailed medical history of the physical symptoms and problems caused by large breasts.
  • Physical Exam: A full physical exam by a healthcare provider to document the severity of the symptoms.
  • Previous Treatments: Evidence of non-surgical treatments tried to alleviate symptoms such as physical therapy, pain medication and supportive garments.

Amount of Tissue to be Removed

Insurance companies have guidelines on the amount of breast tissue removed for the procedure to be medically necessary. This is usually measured in grams and can vary based on the patient’s body size and health status.

Daily Life

Documentation should also include the impact of large breasts on the patient’s daily life including:

  • Physical Activities: How breast size affects ability to exercise and other physical activities.
  • Psychological: Any emotional or psychological distress caused by the symptoms of large breasts.

The Procedure

Breast reduction surgery involves several steps to achieve the best results. Here’s what to expect: Patients should be aware that breast reduction scars are a common complication. These scars typically appear as thin lines that will fade over time.

Consultation and Exam

The process starts with a consultation and exam by a board certified plastic surgeon. During this consultation the surgeon will:

  • Evaluate Your Health: Review your medical history and do a physical exam to evaluate your health and determine if you are a good candidate for surgery.
  • Discuss Your Goals: Discuss your goals and expectations for the surgery including the size and shape of your breasts.
  • Explain the Surgery: Explain the surgical procedure including the techniques used, risks and expected results.

Pre-Surgical Instructions

Before surgery you will be given specific instructions to follow. This may include:

  • Medical Clearance: Get clearance from your primary care physician or any specialists you see.
  • Medications: Stop or adjust certain medications as instructed by your surgeon.
  • Lifestyle Changes: Quit smoking to reduce the risk of complications.

The Surgery

Breast reduction surgery is done under general anesthesia and involves the following steps:

  1. Incisions: The surgeon makes incisions around the areola and down to the breast crease, creating a “keyhole” or “anchor” pattern.
  2. Tissue Removal: Excess breast tissue, fat and skin is removed to achieve the desired breast size and shape.
  3. Reshaping and Lifting: The remaining breast tissue is reshaped and lifted to achieve a more proportional and aesthetically pleasing contour.
  4. Closing Incisions: Incisions are closed with sutures and dressings are applied to support the breasts during healing.

Post-Surgical Recovery

Recovery time will vary from patient to patient but here’s what to expect:

  • Rest and Recovery: Plan to take at least 1-2 weeks off work to rest and recover. No strenuous activities or heavy lifting for at least 6 weeks.
  • Follow-Up Appointments: Attend all scheduled follow-up appointments with your surgeon to monitor your progress and address any concerns.
  • Supportive Garments: Wear supportive garments such as a surgical bra as recommended by your surgeon to support the breasts and reduce swelling.
  • Pain Management: Follow your surgeon’s instructions for pain management including taking prescribed medications and using ice packs to reduce discomfort.

Post-surgery care is crucial for successful breast reductions, and it's important to address common questions patients may have about the procedure.

Risks and Complications

As with any surgery, breast reduction surgery has risks and complications. These may include:

  • Medical Clearance: Get clearance from your primary care physician or any specialists you see.
  • Medications: Stop or adjust certain medications as instructed by your surgeon.
  • Lifestyle Changes: Quit smoking to reduce the risk of complications.

Why New Jersey Plastic Surgery

Choosing the right plastic surgeon for your breast reduction is key to achieving the best possible results, medically and aesthetically. Here’s why New Jersey Plastic Surgery:

  • Board-Certified Surgeons: Our team consists of experienced and board-certified plastic surgeons who specialize in both functional and cosmetic breast reduction. They perform a wide range of plastic surgery procedures.
  • Comprehensive Care: We offer thorough consultations and customized treatment plans to address your unique needs and goals.
  • Advanced Technology: We use the latest surgical techniques and technology to ensure the highest level of care and results.
  • Patient-Centered: We prioritize patient safety, comfort and satisfaction, creating a supportive and caring environment throughout your surgical journey.
  • Proven Results: Our success rate and patient reviews speak for themselves, we are committed to excellence in plastic surgery.

We perform these surgeries at Premier Surgical, a AAAASF accredited facility.

Insurance Approval Process

The insurance approval process for breast reduction surgery can be complicated. Here’s what to expect:

  1. Consultation: Schedule a consultation with a board-certified plastic surgeon to discuss your symptoms and how large breasts are affecting your health and quality of life.
  2. Documentation: Collect all necessary medical documentation including your medical history, physical examination findings, and previous treatments. Contact your insurance carrier to understand their specific requirements and criteria for coverage. Different insurance carriers may have varying criteria for determining medical necessity and the documentation needed.
  3. Insurance Pre-Authorization: Submit the documentation to your insurance company for pre-authorization. This step involves the insurance company reviewing your case to determine if the surgery is medically necessary.
  4. Approval and Scheduling: Once approved, schedule your surgery with your chosen plastic surgeon.
  5. Post-Surgery Follow-Up: Attend all follow-up appointments to monitor your recovery and results.

Final Thoughts

Breast reduction surgery can be life changing for those with medical conditions caused by large, heavy breasts. Knowing what is covered by insurance and going through the approval process will help you get the best results. Cosmetic breast reduction is not covered by insurance, medically necessary breast reduction is. If you think you may be a candidate for medically necessary breast reduction talk to a qualified plastic surgeon to learn more and start your journey to better health and happiness. For more information or to schedule a consultation, contact us today.

New Jersey Plastic Surgery 29 Park St, Montclair, NJ 07042

Our New Jersey Plastic Surgery cosmetic specialists are ready to help you achieve your aesthetic goals with the most advanced treatments the cosmetic industry has to offer. Contact us today to take your first step toward a more beautiful you.

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