Breast lifts (mastopexy) are commonly sought for aesthetic or reconstructive purposes. Aetna’s coverage for breast lifts depends on whether the procedure is deemed medically necessary. Below, we analyze Aetna’s Clinical Policy Bulletins and additional information to clarify when this procedure might be covered.
1. Aetna’s Coverage for Breast Lifts
According to Aetna Clinical Policy Bulletin 0017:
- Medically Necessary Cases: Breast lifts may be covered when performed as part of reconstructive surgery for specific medical conditions, such as:
- Correction of Significant Asymmetry: If asymmetry results from trauma, congenital defects, or breast cancer surgery.
- Post-Mastectomy Reconstruction: As part of reconstruction following mastectomy, breast lifts may be included if they help restore symmetry or balance.
- Cosmetic Procedures: Aetna considers breast lifts performed solely for aesthetic reasons (e.g., sagging due to aging, pregnancy, or weight loss) as cosmetic. Cosmetic procedures are not covered under any Aetna plans.
2. Associated Procedures
According to Aetna Clinical Policy Bulletin 0031:
- Procedures like breast augmentation or reduction are sometimes paired with breast lifts. Aetna may cover these procedures if medical necessity is proven (e.g., to address back pain from large breasts or correct deformities).
3. Insights from Medical Experts
A video by Dr. Rahul Vemula emphasizes that insurance providers like Aetna often deny coverage for breast lifts unless tied to reconstructive or medically necessary procedures. Patients should thoroughly document medical conditions and submit detailed justification from their healthcare provider to improve approval chances.
How to Determine Coverage for Your Case
- Review Your Policy: Check your plan for reconstructive surgery benefits and exclusions.
- Consult Your Doctor: Obtain documentation proving medical necessity, including diagnosis, photos, and supporting tests.
- Submit a Pre-Authorization Request: Most plans require prior approval for reconstructive surgeries.
- Contact Aetna: Speak with a representative to verify coverage specifics based on your policy.
Conclusion
Aetna covers breast lifts only in medically necessary situations, such as reconstructive surgery post-mastectomy or correction of congenital asymmetry. Cosmetic procedures are excluded. Patients seeking insurance coverage for a breast lift should work closely with their healthcare provider to demonstrate medical necessity and consult their specific Aetna plan for details.
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