Does UnitedHealthcare Cover Breast Reduction?
- Some UnitedHealthcare Medicare Advantage plans may help cover breast reduction surgery, but only in limited circumstances for qualified plan members.
Most UnitedHealthcare policies don't cover breast reduction surgery. However, UnitedHealthcare may cover breast reduction surgery if it's required following a mastectomy.
The Women's Health and Cancer Rights Act of 1998 (WHCRA) stipulates that private and group healthcare insurance plans must cover reconstructive surgeries if they also cover mastectomies.
Therefore, you may qualify for coverage if you require a breast reduction to achieve symmetry after a mastectomy and your plan covers mastectomies. You may also be eligible for UnitedHealthcare breast reduction coverage if you need the surgery to preserve your nipple before undergoing a mastectomy.
However, specific UnitedHealthcare plans may cover breast reduction surgery in circumstances not covered by the WHCRA. If your plan includes breast reduction surgery benefits, your doctor must certify that the treatment is medically necessary and reconstructive.
When Is Breast Reduction Surgery Medically Necessary?
UnitedHealthcare may consider a breast reduction medically necessary if you have a condition called macromastia. Individuals with macromastia have breasts that are unusually large compared to the body's proportions, which can sometimes cause associated health problems. Macromastia must be the main cause of any functional impairment you hope to resolve through surgery to qualify for coverage. Furthermore, your doctor must reasonably believe that the surgery will significantly improve any functional impairment.
UnitedHealthcare may consider breast reduction surgery as medically necessary if you have one or more of the following functional impairments:
- Severely raw, itchy or weeping skin (intertrigo) that doesn't respond to less invasive treatments
- Headaches
- Restriction of daily activities due to problems associated with macromastia
- Nerve compression that doesn't improve with other treatments
- Chronic pain in the breasts, upper back, neck or shoulder
- Shoulder grooving caused by bra straps digging in
The above list is not exhaustive. UnitedHealthcare may consider covering breast reduction surgery for other reasons on a case-by-case basis, provided they qualify as medically necessary and reconstructive.
When Is Breast Reduction Surgery Reconstructive?
Whether you qualify for UnitedHealthcare breast reduction coverage also depends on how much tissue your surgeon recommends removing. UnitedHealthcare determines eligibility based on the amount of tissue removed using the Schnur Chart. This chart measures how much tissue is removed per breast compared to the overall body surface area to indicate whether surgery is reconstructive or cosmetic.
If you have a covered functional impairment, your surgery counts as reconstructive if the amount of tissue to be removed plots above the 22nd percentile. UnitedHealthcare considers the surgery cosmetic if the amount plots below the 5th percentile. It determines the eligibility of enrollees plotting between the 5th and 22nd percentiles based on a review of medical evidence.
UnitedHealthcare Breast Reduction Exclusions
Most UnitedHealthcare policies specifically exclude breast reduction surgery unless it falls under the WHCRA. All UnitedHealthcare plans exclude breast reduction surgery performed for cosmetic reasons.
Generally, a breast reduction is considered cosmetic if it doesn't correct a functional impairment or meet the criteria for being medically necessary and reconstructive. UnitedHealthcare doesn't cover breast reductions where liposuction is the only tissue removal method used, even if the beneficiary meets the other eligibility criteria.
UnitedHealthcare policies won't cover breast reduction surgery to correct macromastia caused by a congenital anomaly unless the enrollee also experiences a functional impairment. Psychological symptoms associated with macromastia don't count as a functional impairment, so they won't qualify a beneficiary for coverage.
What Medical Evidence Does UnitedHealthcare Require for Breast Reduction Surgery?
UnitedHealthcare requires medical documentation to determine whether an enrollee is eligible for breast reduction coverage. This documentation should include the beneficiary's weight, height and breast size and include photographs if they have a diagnosis of macromastia.
The medical notes should outline the reasons for seeking a breast reduction and a thorough description of any associated functional impairments. The doctor should also list all tests performed to rule out alternative causes, as well as details about any less invasive treatments attempted to improve any functional impairments.
UnitedHealthcare also requires details of the proposed surgery. These details should include how much tissue the surgeon intends to remove per breast.
