Virtually all of the breast reduction patients at my Long Island practice ask about having health insurance cover the cost of the procedure. It’s possible in many cases, but it’s essential to understand why insurance pays for some breast reduction surgeries but not others.
Insurance companies vary in the type of information they require to cover a breast reduction procedure, but in general you must provide proof that the surgery is “medically necessary” and not simply for cosmetic reasons. In my experience, insurance companies require detailed information from a patient before signing off on coverage for breast reduction. I’ve outlined the basic information you should know if you’re considering undergoing surgery to reduce the size of your breasts:
What does the phrase “medically necessary” mean?
In most cases, women experience physical symptoms that can be linked directly to the weight of overly large breasts. These include:
- Back and/or neck pain
- Rashes that develop where the breasts rub against the skin
- Deep grooves in the shoulders caused by bra straps
What evidence should you submit to the insurance company?
You’ll need to provide documentation from a primary care physician, chiropractor, or orthopedic surgeon detailing your symptoms and recommending breast reduction for relief. Insurance companies sometimes try to have a patient lose weight or pursue other nonsurgical solutions before agreeing to pay for the surgery.
How much breast tissue needs to be removed?
Typically, the surgeon must remove a minimum amount of tissue for the procedure to be covered by insurance. The most frequently used reference for calculating the “medically necessary” amount is a formula called the Schnur scale. It involves comparing the amount of tissue removed to the patient’s body surface area (BSA).
Obtaining insurance coverage is something that our patients don’t have to face alone. We work closely with patients to help them whenever possible. That may include putting together an approval packet that they can submit to their insurance companies. If you’ve been thinking about getting breast reduction surgery to relieve discomfort, it helps to know that women who go through with the procedure are typically among the most satisfied of all plastic surgery patients we see.