Will Your Kaiser Insurance Cover a Breast Reduction?
- Kaiser insurance may cover breast reduction surgery under certain circumstances. Explore medical necessity and other plan requirements for this procedure.
Does Kaiser cover breast reduction surgery? You may qualify for coverage under Kaiser Permanente health insurance plans if your healthcare provider says the procedure is medically necessary.
When Does Kaiser Cover Breast Reduction Surgery?
According to Kaiser's insurance plan documents, the company covers breast reduction procedures when unusually large breast size leads to medical issues. However, coverage excludes reductions done solely for cosmetic reasons.
How Much Does Kaiser Pay for Breast Reduction Surgery?
Coverage depends on your exact plan and its cost-sharing provisions. For example, members of Kaiser's Platinum 90 HMO have a copayment of $250 per day for inpatient hospital stays up to a maximum of $1,250 for the entire stay.
When Is Breast Reduction Medically Necessary?
As discussed, your healthcare provider must document that a breast reduction is medically necessary for your Kaiser plan to provide coverage. Your doctor may diagnose macromastia, or abnormally large breasts, if their size and weight cause:
- Chronic back, neck and/or shoulder pain
- Permanent marks in the shoulders because of bra straps
- Rashes under the breasts that do not heal or go away and come back
Kaiser will also cover breast reduction related to reconstruction after mastectomy.
How Can I Show Medical Necessity for Breast Reduction?
Before you can receive coverage for breast reduction surgery through Kaiser, you have to apply for authorization. Some documents the insurance company may require to prove medical necessity include:
- Medical records that detail your height, weight and breast size
- Photos of your breasts
- A letter from your healthcare provider explaining the symptoms that arise because of your breast size
- Notes about how your breast size affects your life, such as limiting your ability to engage in physical activity
Generally, you must have proof from a doctor that you have medical symptoms arising from your breast size. You also have to show that you have tried other treatments, such as diet and exercise, that have not been successful.
What May Disqualify You for Breast Reduction Coverage?
Kaiser may decline to cover your breast reduction if the company finds the procedure does not meet its medical necessity requirements. You may also be disqualified if you cannot safely have the surgery. For example, you might have to lose weight, treat chronic health conditions or quit smoking before Kaiser will cover your breast reduction.