Does Aetna Cover Breast Reduction?

Breast reduction surgery (reduction mammoplasty) is a procedure that involves removing breast tissue to reduce the size of the breasts. You may wish to have a breast reduction for cosmetic reasons or to relieve any pain and discomfort caused by having large breasts. 

Breast reduction surgery without insurance coverage is expensive, so it's worth checking whether your insurer includes reduction mammoplasty as a benefit. This article explains Aetna's breast reduction eligibility requirements and who may qualify for coverage. 

Does Aetna Cover Breast Reduction Surgery?

Aetna may cover medically necessary breast reduction surgery in limited circumstances, and you should check your policy to see if it's a covered benefit. If you're not already an Aetna member, you may click below to shop for plans in your area.

You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. 

When Is Breast Reduction Surgery Medically Necessary?

Aetna will usually cover reconstructive breast surgery following a medically necessary mastectomy if your policy covers the mastectomy itself. That's because the Women's Health and Cancer Rights Act (WHCRA) of 1998 requires all insurers to cover reconstructive procedures if they also cover mastectomy.

Therefore, you may receive coverage for breast reduction surgery to make your breasts appear symmetrical after a mastectomy or lumpectomy. Furthermore, Aetna may cover breast reduction surgery as part of a reconstructive procedure if your breasts are asymmetrical because of a traumatic injury. 

Otherwise, Aetna may consider covering your treatment if you have macromastia, which means that your breasts are exceptionally large for your body size. You must exhibit at least two of the following symptoms to qualify for Aetna breast reduction coverage:

• Headaches
• Neck, upper back or shoulder pain
• Kyphosis (abnormal curvature of the spine) that causes pain
• Painful, irritated or ulcerated skin around the breasts or bra strap area
• Paresthesia (burning or prickling sensations) in your arms or hands

You're only eligible for coverage if macromastia is the primary cause of your symptoms and you've been experiencing symptoms for at least a year. Furthermore, you must try other appropriate, conservative treatments for your symptoms for at least three months (or at least six months for dermatologic complaints.) These treatments could include pain relief medications, physical therapy, weight loss or dermatologic treatment. 

Finally, Aetna may consider breast reduction surgery medically necessary to treat gigantomastia of pregnancy. Gigantomastia of pregnancy is a rare condition that causes significant enlargement of one or both breasts. You will only qualify for coverage if you have accompanying symptoms, such as breast ulceration, necrosis, infection or hemorrhage and you are not near your expected due date. 

What Are Aetna's Breast Reduction Weight Requirements?

Aetna only covers breast reduction surgery if your surgeon intends to remove a significant amount of breast tissue. The company compares the amount of removed breast tissue to your body area to decide if your surgery is medically necessary. You can find the weight thresholds for breast reduction eligibility through Aetna in this table. 

However, you may qualify for coverage if your surgeon plans to remove a minimum of 1kg of tissue from each breast, regardless of its proportion to your body area. 

Aetna Breast Reduction Coverage Exclusions

Aetna explicitly excludes cosmetic breast reduction surgery from all its policies. Therefore, you won't qualify for coverage if you don't meet the criteria for a medically necessary procedure or your breast size doesn't cause any physical symptoms. Furthermore, it excludes experimental surgical techniques, including liposuction as the only treatment method and radiotherapy. 

Aetna doesn't cover breast reduction surgery to treat gynecomastia. Gynecomastia is a condition that causes breast tissue growth in males. Aetna considers corrective surgery cosmetic because it isn't proven to improve pain in people with gynecomastia. However, your policy may cover other, less invasive treatments to address the underlying causes of your condition.

Aetna Breast Reduction Documentation Requirements

Aetna will likely require medical evidence to demonstrate that a breast reduction procedure is medically necessary. Your doctor must provide photographic evidence showing significant breast hypertrophy if you need surgery to treat macromastia symptoms.

Furthermore, they may need to provide details of any conservative options you've tried to improve your condition and explain why breast reduction is the most appropriate next step. Your doctor should also certify that the procedure is likely to provide relief from your symptoms.