How to Get a Breast Reduction in NJ & NYC Covered by Insurance

Living with overly large breasts can significantly affect your daily life, leading to various issues like back pain, irritation, and posture problems. If you are considering breast reduction, you are probably wondering how much your procedure will cost and whether it will be covered by health insurance. At Rowe Plastic Surgery, we offer medical breast reduction, and we can help you through all the steps, including sorting out your insurance coverage, so you can have the comfort and freedom you deserve.

Health Conditions That Require Breast Reduction

Huge breasts can lead to numerous medical issues that interfere with daily life, making breast reduction surgery a medical necessity and thus eligible for insurance coverage.

Some of the conditions that might warrant a medically necessary breast reduction include:

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

How to Get a Breast Reduction Covered by Insurance

Many women want to lift their breasts, have a bigger bosom or fix their sagging bust. Others, maybe including you, suffer with breasts that are so big that they interfere with your life.

Super big boobs, clinically called symptomatic macromastia, create a host of uncomfortable complications, including:

• Chronic shoulder, neck and back pain. Large breasts can cause chronic pain in the shoulders, neck, and back due to the strain of supporting excess weight. Breast reduction can alleviate this pain, improving posture and overall comfort.
• Rashes and dermatitis underneath your breasts. Excess skin and moisture under large breasts can lead to rashes and dermatitis. Reducing breast size can help prevent these skin conditions, promoting better hygiene and comfort.
• Activity restrictions. Women with large breasts often face limitations in physical activities due to discomfort and pain. Breast reduction can enable a more active lifestyle, allowing participation in sports and other physical activities.
• Nerve pain. The weight of large breasts can compress nerves, leading to pain and numbness. Breast reduction can relieve this nerve pain, improving sensation and reducing discomfort.
• Poor posture. Carrying the weight of large breasts can lead to poor posture, which can cause additional musculoskeletal issues. Breast reduction can help correct posture, reducing the risk of long-term complications.
• Embarrassment and low self-esteem. Large breasts can cause embarrassment and negatively impact self-esteem. Breast reduction can enhance body image and boost confidence, leading to a better quality of life.
• Breathing problems. Large breasts can compress the chest and restrict breathing. Breast reduction can improve respiratory function, making breathing easier and more comfortable.
• Skeletal deformities. The strain of supporting large breasts can lead to skeletal deformities over time. Breast reduction can help prevent these deformities, promoting better skeletal health.
• Abscesses and infections. Excess skin and moisture under large breasts can create an environment prone to abscesses and infections. Breast reduction can reduce the risk of these complications, promoting better overall health.
• Lost feeling in your nipples. The weight of large breasts can compress nerves, leading to a loss of sensation in the nipples. Breast reduction can help restore sensation, improving overall comfort.
• Fatigue and headaches. The constant strain of supporting large breasts can cause fatigue and headaches. Breast reduction can alleviate this strain, reducing fatigue and improving overall well-being.
• Sweat gland obstruction. Large breasts can obstruct sweat glands, leading to excessive sweating and discomfort. Breast reduction can help reduce sweating, promoting better hygiene and comfort.
• Hand pain and numbness. The strain of supporting large breasts can cause pain and numbness in the hands. Breast reduction can relieve this strain, improving hand function and reducing discomfort.
• Ridges and grooves on your shoulders from the pull of your bra straps. The pull of bra straps on large breasts can cause ridges and grooves on the shoulders. Breast reduction can help prevent these skin changes, promoting better skin health. Breast reduction surgery can significantly improve the quality of life for women experiencing these conditions, offering both physical and psychological benefits.

Since macromastia can create these devastating medical conditions, your health insurance company may pay for boob reduction surgery in NYC, and NJ. As you consider getting a breast reduction, be sure to talk with an experienced plastic surgeon who knows the issues surrounding large, droopy breasts and the sometimes-complicated process of getting breast reduction insurance coverage. In Manhattan, Long Island, New Jersey and the Hamptons, you’re in the best hands at Rowe Plastic Surgery.

What Are the First Steps to Getting Breast Reduction Covered by Insurance?

First, contact your insurance carrier to find out what their particular requirements are to get the procedure covered. While you may know a friend whose breast reduction surgery covered by insurance, your personal health insurance carrier may have an entirely different set of criteria.

In general, you’ve got to have some proof that you have medical issues from your large breasts. This proof must come from a doctor or medical professional other than your plastic surgeon.

In most cases, you must have undergone treatment for anywhere from six to 12 months from providers such as a:

• Physical therapist
• Internist or primary care doctor
• Chiropractor
• Orthopedist
• Dermatologist
• Pulmonologist
• Rheumatologist
• Nutritionist

How Do I Know if I Have Enough Documentation?

Chances are that you’ve already talked to your primary care doctor about your various symptoms. Your general practitioner or internist probably referred you to specialists to try to relieve your pain and discomfort. If you haven’t been treated specifically for a condition related to the size of your breasts, ask your primary care doctor to make a referral so you can get the reports you need for your breast reduction insurance.

At Rowe Plastic Surgery, the staff is fluent when it comes to insurance-speak. They can point you in the right direction to get covered for breast reduction surgery. They’ll even help you fill out the required paperwork.

Some of the documentation required to prove medical necessity for breast reduction surgery includes:

• Medical Records: Detailed medical records documenting the patient’s history and symptoms.
• Physician’s Notes: Notes from the treating physician explaining the medical necessity.
• Photographs: Clinical photographs of the breasts to visually document the condition.
• Previous Treatments: Documentation of previous treatments attempted and their outcomes.
• Impact on Daily Life: Records showing how the condition affects the patient’s daily activities and quality of life.

Some of the treatments that help you qualify for insurance for breast reduction include:

• Chiropractic adjustments
• Prescriptions for a proper bra fitting
• A weight loss program
• Pain medications

Read more: Mammoplasty in NJ

Is Breast Reduction Surgery Ever Automatically Covered by Insurance?

Some insurance companies only pay breast reduction surgery insurance for patients over the age of 18. When younger girls experience rapid breast growth, it may be cause for concern and more immediate intervention. The massive and often quick growth may be caused by a reaction to gonadal hormones. While this usually affects adolescent girls, it’s still recommended that you wait until your breasts have completely developed before seeking the surgery.

You won’t need to document a history of trying to relieve symptoms caused by large breasts when your surgery is tied to:

• Breast reconstruction after a mastectomy
• Progressive spine issues that don’t resolve with other treatments
• Intertrigo, which refers to persistent infections under your breasts

What to Do if Insurance Denied My Breast Reduction Surgery?

If your request for breast reduction is denied, but you believe it is crucial for your health and well-being, you have the legal right to appeal the decision.

• Review the Denial Letter: Carefully read the denial letter from your insurance company to understand the reasons for the denial.
• Gather Supporting Documentation: Collect all relevant medical records, including notes from your primary care doctor, specialists, and any other healthcare providers who have treated you for symptoms related to your breast size. Include clinical photographs, documentation of previous treatments, and records showing the impact on your daily life.
• Write a Personal Appeal Letter: Draft a letter describing your symptoms, how they have affected your quality of life, and why you believe breast reduction surgery is medically necessary. Focus on the physical problems rather than cosmetic concerns.
• Get Letters from Healthcare Providers: Request letters from your primary care doctor, orthopedist, physical therapist, chiropractor, or massage therapist supporting your appeal. These letters should detail your symptoms and the treatments you have tried that have been unsuccessful.
• Submit the Appeal: Submit your appeal letter along with the supporting documentation to your insurance company. Follow the specific instructions provided in the denial letter for submitting an appeal1.
• Request a Peer-to-Peer Review: Ask your plastic surgeon to set up a peer-to-peer review with the insurance company on your behalf. This involves a discussion between your surgeon and the insurance company’s medical reviewer to explain the medical necessity of the surgery.
• Follow Up: Keep track of your appeal and follow up with your insurance company if you do not receive a response within the expected timeframe.
• Consider State Insurance Department: If your appeal is denied and you believe the decision was unfair, you can file a complaint with your state’s department of insurance. Some states have mandates for breast reduction coverage.
• Explore Alternative Financing Options: If your appeal is ultimately denied, discuss alternative financing options with your surgeon, such as payment plans or medical credit lines.

When Approved, What’s Included in Breast Reduction Surgery?

Once you’ve completed all the requirements and paperwork to get approval from your insurance company, your cosmetic surgeon explains what you can expect from the surgery. After taking a detailed medical history, your doctor discusses your expectations and takes pictures for before and after comparisons.

Breast reduction surgery is an outpatient procedure that is done for both women and men (gynecomastia surgery) and takes one and a half to two hours under general anesthesia. You’re also given a shot of pain medication that lasts three to five days. Prior to the surgery, you may be asked to undergo some lab tests and get a mammogram to give your doctor a baseline.

Steps your Rowe Plastic Surgery team take typically include:

1. A surgical technique called a lollipop incision relies on fewer incisions, leaving smaller scars. While your insurance doesn’t cover breast reductions for cosmetic reasons, your NJ or NYC plastic surgeon aims to provide you with a natural and more youthful appearance.
2. Your nipples may remain in place, although usually your areolas are reduced to match your new breast size.
3. If necessary, your nipples may need to be removed and grafted higher up. They’ll feel just as they did before the surgery once they heal.
4. Liposuction removes the excess fat in your breasts.
5. Once the fat and extra glandular tissue are removed, your doctor tightens the skin around your breasts so they better match the rest of your body.
6. Once the procedure is complete, your breasts are fitted with a drainage tube, if necessary, and wrapped.
7. Follow-up visits after about six weeks are included in the surgical costs, which are also covered by insurance for breast reduction.

Cost of Breast Reduction Without Insurance

The average cost of breast reduction surgery without insurance in New Jersey typically ranges from $8,000 to $21,000. This wide range accounts for various factors such as the surgeon’s fee, anesthesia, surgical facility fees, and other related expenses. Contact Rowe Plastic Surgery to get a detailed quote tailored to your specific needs.

*Price range is based on a national average of Breast Reduction Surgery not specific to Rowe Plastic Surgery.

Breast Reduction Recovery

Immediate Post-Surgery (First 24 Hours)

• Pain Management: You’ll likely be on pain medication to manage discomfort.
• Assistance Needed: It’s essential to have someone help you with daily activities, as your range of motion will be limited.
• Compression Garment: You’ll wear a compression garment or surgical bra to support the healing process.

Days 2-3: Initial Recovery Period

• Medication: Continue taking prescribed medications.
• Mobility: Start to regain some mobility but avoid any strenuous activities.
• Light Walking: Engage in light walking to improve blood circulation and prevent blood clots.

Week 1: Critical Recovery Phase

• Rest: Prioritize rest and avoid strenuous activities.
• Pain Medication: Follow your medication schedule as prescribed by your doctor.
• Diet: Eat a balanced diet rich in vitamins and minerals to speed up healing.
• Salt Intake: Keep salt intake low to reduce swelling.

Week 2: Signs of Progress

• Follow-Up Appointments: Attend follow-up appointments to assess healing and remove stitches if necessary.
• Resuming Activities: Gradually reintroduce daily activities but avoid heavy lifting and strenuous exercise.

Weeks 3-4: Returning to Routine

• Daily Tasks: Many patients can return to work and handle daily tasks with ease.
• Continued Caution: Continue to avoid heavy lifting and strenuous exercise.

Long-Term Recovery (3-4 Months)

• Full Results: Most patients see full results after 3-4 months, though recovery rates vary.

Risks and Complications

• Anesthesia Risks: As with any surgery requiring general anesthesia, there are risks associated with anesthesia, including allergic reactions and complications related to breathing.
• Bleeding (Hematoma): Post-surgery bleeding can lead to a collection of blood (hematoma) under the skin, which may require drainage.
• Infection: Although rare, infections can occur at the incision sites and may require antibiotics or additional treatment.
• Poor Wound Healing: Some patients may experience delayed healing or wound breakdown, which can prolong recovery.
• Changes in Nipple or Breast Sensation: Numbness or changes in sensation in the nipples or breast skin can be temporary or permanent.
• Breast Asymmetry: There may be differences in breast size or shape post-surgery, which might require additional procedures to correct.
• Scarring: Scarring is inevitable with any surgical procedure, and the visibility of scars can vary depending on individual healing and surgical technique.
• Fat Necrosis: Fat tissue deep within the breast may die, leading to firm lumps that may require surgical removal.
• Fluid Accumulation: Accumulation of fluid (seroma) under the skin can occur and might need to be drained.
• Damage to Deeper Structures: There is a risk of damage to nerves, blood vessels, muscles, and lungs during surgery, which can be temporary or permanent.
• Deep Vein Thrombosis (DVT): Blood clots can form in the legs, which can be dangerous if they travel to the lungs (pulmonary embolism).
• Excessive Firmness: The breast may feel excessively firm or hard, which can be uncomfortable.
• Difficulty Breastfeeding: Breast reduction surgery can affect the ability to breastfeed, although many women can still breastfeed after the procedure.
• Unfavorable Scarring: Scarring may be more prominent or less favorable than expected, and revisional surgery might be needed.
• Loss of Skin or Tissue: There is a risk of partial or total loss of skin or tissue where the incisions meet.
• Skin Discoloration and Pigmentation Changes: Changes in skin color and pigmentation can occur, which may be permanent.
• Pain: Persistent pain may occur and might require additional pain management strategies.

Is Breast Reduction Surgery Worth the Effort?

You have to limit your activities for about a month after surgery, but you can return to work within a week. Other than that, there’s very little downtime. Recovery from breast reduction surgery means avoiding underwire bras, but you may consider that a bonus.

The biggest benefit to going through the surgery approved by your insurance company is that you’ll feel so much better. You may even find that you can participate in sports and exercises that used to be out of your league. You experience no more back aches, neck strains or stiff, marked shoulders. The rash underneath your boobs clears up, never to return. Risks are rare when you rely on experts in breast reduction surgery, but all of them are easily manageable.

Maintain your ideal weight and the results are permanent. To begin the process of getting on your breast surgeon’s schedule, contact Rowe Plastic Surgery today. The staff works with you to determine what steps you need to take to get insurance approval. There’s no reason to wait. Visit the closest office in Manhattan, Plainview or Water Mill, NY or in Montclair or Red Bank, NJ.