What to Know About Breast Surgery and Insurance

Breast surgery isn’t typically a decision someone makes on a whim, and in fact, plastic surgeons discourage that. The main reason is that breast augmentation is a major surgery that can impact a person both physically and mentally, and therefore should be well thought-out, but also because it’s not generally covered by insurance. Here, leading plastic surgeons explain which breast procedures are covered and which ones aren’t, so you can be prepared before your consultation.

Cosmetic Breast Surgery Is Not Covered

Chicago plastic surgeon Michael Horn, MD says cosmetic breast surgery such as breast augmentation with breast implants or breast lifts, are not covered by insurance, and therefore the patient is responsible for the cost. “Before scheduling a plastic surgery consultation, you should always find out beforehand if the doctor accepts insurance as payment for the type of breast surgery you are interested in, keeping in mind that cosmetic breast surgery is not covered by insurance,” adds Tucson, AZ plastic surgeon Raman C. Mahabir, MD.

Breast Reduction Surgery Might Be Covered

However, Pasadena, CA plastic surgeon Lily Lee, MD says breast reduction is one of the few breast surgeries (aside from reconstruction; more on that below) that is covered. “What is covered is dependent on your insurance policy, and most insurance companies will publish their policy criteria online. When determining if a patient is covered, they want to know that the patient has exhausted all nonsurgical options first, such as physical therapy, weight loss, rash management, etc. I tell patients seeking a breast reduction covered by insurance that the insurance company has a minimum resection weight requirement, which is calculated based on their Body Surface Area (BSA). How much is resected is not determined by me, the surgeon. In my practice, we will calculate that weight and I will give the potential patient a breast implant with similar weight to hold. I ask them, are you OK losing this much from each breast? If so, then we have a good insurance candidate.” 

Breast Reconstruction Surgery Is Covered

“Insurance typically covers two categories of breast surgery: The first is breast reconstruction surgery after breast cancer, and the second is breast reduction surgery in women who are medically symptomatic from their excessively large breast volume,” explains Dr. Mahabir.

According to information published in The Breast Reconstruction Guidebook, which is also provided on Breastcancer.org, “breast reconstruction procedures should be covered by your health insurance plan, whether they are done right away, soon after mastectomy/lumpectomy, or many years later. This includes procedures that may be needed over time to refine the reconstructed breast and/or to create symmetry (balance) between the two breasts.

The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state. Government- and church-sponsored plans are not necessarily required to cover reconstruction, so you may need to check with your plan administrator. Even if you’re covered, it’s still possible to run into problems, especially in certain situations: For example, maybe you’ve chosen a newer type of reconstructive procedure, you’re having surgery to create a more balanced appearance, or you need a complete correction of a past reconstruction. Coverage also can be an issue if you want to use a plastic surgeon who is outside your health insurance plan’s network. It’s always best to communicate with your health insurance provider up front and check on what exactly is covered so you can avoid the work of trying to get payment later.”

It's Personal

At NewBeauty, we get the most trusted information from the beauty authority delivered right to your inbox

Find a Doctor

Find a NewBeauty "Top Beauty Doctor" Near you

Select a state State AL AR AZ CA CO CT DC FL GA HI IA IL IN KY LA MA MD MI MN MO NC NE NJ NV NY OH OR PA SC TN TX UT VA WA WI Select a state Specialty Cosmetic Dentist Dermatologist Facial Plastic Surgeon Hair Restoration Specialist Oculoplastic Surgeon Periodontist Plastic Surgeon Prosthodontist Vein Specialist Select a state Treatment Abdominal thread lifts Accent your Body Acne Treatments Alexandrite Laser Arm Lift Asclera Bellafill Belotero Blue Light Body Body Lift Botox Botox Browlift Brachioplasty Brazilian Butt Lift Breast Augmentation Breast Augmentation with Fat Grafting Breast Implants Breast Implants with Saline Breast Implants with Silicone Breast Lift Breast Lift with Implants Breast Reconstruction Breast Reduction Browlift Butt Enhancement Carboxytherapy Cellulite Treatment Cheek Augmentation Cheek Augmentation with Fat Grafting Cheek Implants Cheek Lift Chemical Peels Chin Augmentation CO2 lasers Cool Lipo CoolSculpting CoolTone Crowns Dental Bonding Dental Implants Dimpleplasty Diode Laser Dysport embrace Active Scar Defense Emsculpt Endermologie Endoscopic Browlift Endoscopic Facelift Endoscopic Tummy Tuck Erbium Lasers Exilis Ultra 360 Eyelift Eyelift with Fat Grafting Face Facelift Facelift with Fat Grafting FaceTite Fat Melters and Fat Reducers Fat Transfer Forma Fractional CO2 lasers Fractional Resurfacing Lasers Fractora Glycolic Peels Glytone Enhanced Brightening Cream Gum Dermabrasion Gum Lift Hair Hair Removal Hair Transplant Hair-Loss Treatment Injectables & Fillers for Cheek Augmentation Injectables & Fillers for Eyelift Injectables & Fillers for Lip Enhancement Injectables And Fillers Injectables and Fillers with Fat Grafting Intense Pulsed Light (IPL) Invisalign Isolaz Juvéderm Juvéderm Volbella Juvéderm Voluma Kybella Lactic Acid Peels Laser Liposuction Lasers Lateral Tension Tummy Tuck Limited Incision Facelift Lip Enhancement Lip Enhancement with Fat Grafting Lip Implant Lip Lift Liposculpture Liposuction Liquid Facelift Long Pulsed N: Yag laser Lower Blepharoplasty Lower Body Lift Lower eyelid surgery Lower Facelift MACS Lift Mandelic Peels Microdermabrasion Microinjection Microneedling Microwave Laser Treatment Mini Tummy Tuck Mini-Facelift Mommy Makeover Nd: Yag Neck Liposuction Necklift Nonsurgical Facelift Nonsurgical Rhinoplasty Obagi Blue Peel Otoplasty Perlane Phenol Peels Photobiomodulation Photodynamic Therapy (PDT) Photofacial PiQo4 Plasma Resurfacing Lasers Power Assisted Liposuction Prevelle Pulsed Dye Radiesse Radio Frequency with Microneedling Radio Frequency-Assisted Lipolysis Red Light Restylane Restylane Defyne Restylane Lyft Restylane Refyne Restylane Silk Revision Rhinoplasty Rhinoplasty Salicylic Peels SculpSure Sculptra Aesthetic Selphyl Silhouette Instalift Skin Skin Tighteners Skin Treatments Slim Lipo Smart Lipo SMAS facelift Smile Smile Makeover Smoothshapes Straightening Stretch Mark Treatments TCA Chemical Peels Teeth Whitening Thermage ThermiTight Thigh Lift Titan Tooth Contouring Traditional Facelift Tumescent Liposuction Tummy Tuck Ulthera Ultherapy Ultrasound Assisted Liposuction Umbilicoplasty Upper Blepharoplasty Upper eyelid surgery Vanquish ME VASER Lipo Vein Treatments Velashape Velasmooth Veneers Xeomin Search