Does Medical Aid Cover Breast Reduction Surgery in South Africa?

An increasing number of women are opting for breast reduction as a way of relieving the pain that sometimes accompanies large breasts and balancing the body. Excessively large breasts can cause chronic neck and back ache, skin irritation, shoulder aches and make the performance of even the simplest of daily tasks more difficult. But what many women want to know is just how much the procedure will cost and whether their medical aid will pay for it.

Medical aid cover for breast reduction in South Africa is calculated by the severity of the medical condition of the patient, with approval by the medical scheme. Knowing the cost and approval needed beforehand is a must.

Is Breast Reduction Surgery Covered by Medical Aid South Africa?

Your breast reduction might be funded by your medical aid if it can be classified as a medically necessary surgical procedure and not just a cosmetic procedure. Your surgeon makes an application to the medical scheme and you are assessed in terms of your physical symptoms, medical history and medical reports.

The patient might potentially be able to claim for medical aid if the medical problems with breasts that are too large permanently disables her. But there is no guarantee, as each scheme has its own terms and conditions and benefits.

Medical Conditions That May Justify Coverage

Medical aid providers could do this to any of the following patients:

• Pain in back, neck and shoulders due to breast weight.

• Shoulders are deep grooves from bra straps.

• Repeated irritation, rash or infection below the breasts.

• Difficulty with exercise or physical activity.

• Posture problems from breasts that are too large.

• Persistent physical discomfort affecting everyday activities.

When it comes to written documentation, you need to have medical documentation to support that the primary reason for the surgery is to address a physical symptom rather than for cosmetic purposes.

What Documents Are Required for Medical Aid Approval?

Before approving breast reduction, here is the documentation that may be required. Medical schemes may request documentation in order to assess whether the breast reduction qualifies as medically necessary.

Preparing the information available, however, can also help patients get the answer to that question.

1. Medical Assessment and Specialist Report

The first thing is to have a consultation with a qualified plastic surgeon. The plastic surgeon will examine the size of your breast, possible symptomatology, physical pain and estimate if the breast reduction is the indication of breast reduction.

For instance, a medical report might include the patient's symptoms and findings during an examination along with the required surgical procedures.

2. Medical History and Previous Treatments

Some medical aids will want to know if you have been treated for this problem before or if you have attempted to treat the symptoms without surgery.

The treatment may be physiotherapy, pain management, skin treatments or other treatment for any other conditions the patient has.

3. Supporting Medical Evidence

Some schemes may require proof such as a photo, referral letter or medical records to process an application.

Always confirm with your medical aid fund exactly what documents they require before you apply.

What Factors Affect Medical Aid Coverage?

But not every breast reduction will be covered by medical aid. Below are some of the considerations.

Medical Necessity

Procedures are generally categorized as being either diagnostic or therapeutic (done to address a medical problem), or cosmetic.

A patient with actual pain is more likely to have a more solid argument for reimbursement than a patient who chooses to undergo surgery to change their looks.

Medical Scheme Rules & Benefits

Different plans with exclusions and surgical benefits are available from different medical aid providers. Some may have a specific minimum breast size, or not cover certain surgeries altogether.

Patients should know what their membership benefits and enquire about specialist consultation, hospital charges, costs of anaesthesia and operation.

Pre-Authorisation Requirements

An example is that certain schemes, for instance, have pre-authorisation where all planned surgery has to be pre-authorised. The patient will have to submit all the necessary medical information and gain approval before the operation.

Even if a surgeon recommends it, your medical aid may not cover the procedure.

What If Medical Aid Does Not Cover Breast Reduction?

Are there any other options if I am not successful with my application for medical aid?

The first step is to check why your claim has been rejected. Patients can request a medical scheme to give an explanation or to allow them to submit an additional medical report or to appeal the decision.

Surgical Quote May Consist Of:

• Plastic surgeon's professional fees.

• Anaesthetist's fees.

• Hospital and theatre charges.

• Medication and post-operative care.

• Follow-up consultations.

The overall amount will depend on the extent of the operation, the hospital where the operation is conducted, and the needs of the patient.

How to Prepare Your Finances for Breast Reduction Surgery

Deciding ahead of time can lighten the whole process and help you prevent surprises.

Before the Operation:

1. Contact your medical aid to see if you are covered for breast reduction.

2. Ask the quantity needed and what might not be involved.

3. Schedule an appointment with a board-certified plastic surgeon.

4. Specify requesting a report in detail and all reports.

5. Secure your pre-authorisation application first.

6. If your funding application is turned down, be sure to obtain a detailed private surgical quotation.

7. It's always wise to save up for additional visits and healing.

What to Look for in a Breast Reduction Clinic in South Africa

Selecting the right surgeon and hospital is equally crucial as the treatment cost for surgery. The patient should be aware of the surgeon's expertise and the hospital quality, consultation process, after care, and team.

Before making a decision, it is equally important to talk about possible surgical results, complications, scarring, and expected recovery.

When looking for Breast reduction Cape Town the solution is to choose a clinic that makes it easy to find out about the procedure, the cost and the recovery period.

Explore Breast Reduction Surgery at Your Breasts

Medical aid cover has been an important consideration when planning a breast reduction, but every case is different. If you are thinking about surgery because of physical pain or want to explore your options, we offer a consultation which can help you determine the best course of action.

A guide for patients seeking breast surgery in Cape Town, South Africa. The breast reduction clinic can explain to you what you should expect, surgical options and the costs of surgery.

If so click on Your Breasts for further information, and to book a consultation to have a one-to-one discussion with an expert who can assess your personal suitability and options. This personalised assessment provides clarity about the next steps towards a confident decision.