Insurance companies look closely at the various breast enhancement/reduction surgeries to determine when a procedure is medically necessary. Breast augmentation (not related to breast reconstruction after breast cancer treatment) is not covered, because it is considered purely cosmetic. There are two categories of surgeries generally covered by insurance: breast reduction (often covered) and breast reconstruction (always covered).

Breast Reduction
Your chances of getting coverage for breast reduction surgery, or reduction mammoplasty, are pretty good. Insurance companies recognize the medical necessity of breast reduction, since the surgery can help relieve symptoms like back and neck pain, as well as pain/skin irritations from bra straps cutting into shoulders. However, there are also cosmetic reasons why a woman would have the surgery. The key is finding out ahead of time what your insurance company requires in the way of documentation (and what exactly they cover, such as lab costs, anesthesia, follow-up visits, etc), and then following the instructions for documentation very carefully

Your surgeon will need to draft a letter to your insurance company. He/she should take photos of your breasts, and include all of your physical symptoms caused by overly breasts in the letter. Depending on your carrier, in the letter, the surgeon may also need to talk about how much breast tissue will be removed from each breast (some insurance companies have minimums).

Men also suffer from excess breast tissue, called gynecomastia. It can be caused by hormone disorders, excess fat, and increasing age. With gynecomastia, it’s important to try to determine the underlying cause and to try to treat it before surgery. If surgery is ultimately what you and your doctor decide on, know that gynecomastia surgery is not usually covered by insurance. It’s always worth trying though. In fact, the American Society of Plastic Surgeons (ASPS) has made recommendations for insurance companies to cover gynecomastia surgery; ask your doctor to submit a copy of this to your insurance company.

Breast Reconstruction
Breast reconstruction is, by law, covered by insurance. The Women’s Health and Cancer Rights Act of 1998 requires group health plans and health insurers providing medical and surgical benefits for mastectomy to cover the cost of reconstructive breast surgery for women who have had a mastectomy. The coverage also includes surgery on the other breast to achieve symmetry. However, plans still vary in their coverage (and may not cover everything about the surgery). Check with your insurance company.