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Health Insurance & Breast Reduction – What You Should Know

Women with overly large breasts often complain of back pain, shoulder pain, neck pain, headaches, and breast pain, as well as rashes, wounds and sores along the undersurface of the breasts.  Although breast reduction (reduction mammaplasty) has been demonstrated to alleviate symptoms associated with macromastia and improve quality-of-life, the amount of tissue required for excision to provide medical benefit has yet to be demonstrated.  Breast reduction surgery is therefore considered by the American Society of Plastic Surgeons (ASPS) to be medically necessary when one or more of the following symptoms are documented:

  1. Chronic breast pain due to weight of the breasts
  2. Intertrigo unresponsive to medical management
  3. Upper back, neck, and shoulder pain
  4. Backache, unspecified
  5. Thoracic kyphosis, acquired
  6. Shoulder grooving from bra straps
  7. Upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area
  8. Headache
  9. Congenital breast deformity

The recommendations of the ASPS are based on prospective outcomes studies and meta-analyses that essentially demonstrate no correlation between amount of breast tissue excised and relief of preoperative symptoms.  Unfortunately, when symptoms are self-reported, it is difficult to determine medical necessity as reduction mammplasty can be performed for cosmetic reasons. As a result, although the specifics vary from company to company, most major health insurance carriers have well-defined criteria that must be met in order to cover the costs associated with breast reduction.  These criteria usually fall into three distinct categories:

  • Documentation of symptoms.  Merely telling a plastic surgeon that you suffer from pain or rashes is not adequate.  To truly document symptoms related to overly large breasts, clinic notes from physicians other than a plastic surgeon demonstrating visits related to these problems is a must.
  • Failure of nonoperative treatment.  Most major insurance companies require documentation that nonoperative treatment, including physical therapy, chiropractic treatment, anti-inflammatory medications, and use of wide-strapped bras, have been tried and failed over a defined period of time.  Some insurance companies require documentation over a span as short of 6 weeks, others range to as long as 6 months.
  • Minimum weight requirement.  Although good data exist demonstrating no correlation between the amount of breast tissue removed and relief of preoperative symptoms, most insurance companies still have a minimum weight requirement of excised breast tissue.  Their rationale for this is that small breast reductions are akin to breast lifts (mastopexy), and thus, are more likely to be cosmetic in nature.  Many insurance criteria utilize the Schnur scale, which determines the minimum amount of excised breast tissue in relation to the patient’s body surface area, which is calculated with their height and weight.  The more a patient weighs and the taller they are, the more breast tissue needs to be removed.

As is quite evident, some hoops need to be jumped prior to getting approval from your insurance carrier prior to breast reduction, even if the procedure is medically necessary.  It is important to check with your insurance carrier to see if breast reduction is a covered procedure and, if so, what the criteria for coverage are.  Often times, the criteria is too difficult to meet or breast reduction is an excluded procedure entirely.  In these cases, the procedure can be done for a set price with your local, board certified plastic surgeon.

To learn more about breast reduction contact Dr. Sam Jejurikar at 214-827-2814.

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Our Location Dallas Plastic Surgery Institute

9101 N. Central Expwy.
Suite 600, Dallas, TX 75231
Tel: 214.827.2814
Dallas | Dr. Jejurikar

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