Medical Criteria for Insurance coverage of Breast Reduction

Lavinia Chong, MD
Article by
Orange County Plastic Surgeon

A woman's breast symbolizes many aspects of her being: femininity, maternity, attraction, youth.  As much as small busted women struggle to maintain the position, volume mobility and tactile  quality of their breasts, their heavy busted sister is afflicted with additional concerns.  She is obliged to wear supportive undergarments, may be limited in her activities of daily living and dissatisfied with her body image.  In contemporary America, we are incessantly imprinted with images of idealized breasts.  Eventually the heavy busted woman may seek consultation with a PS to discuss surgical options.     

In addition to taking a complete history and physical, the PS should also discuss the patient's aesthetic ideals, prior to undertaking to write a letter to their insurance company to request preauthorization for outpatient surgical services.  The "case" can be strengthened by including photographs, as well as supporting letters from her primary care physician and other specialists who have attended her because of her symptomatic "macromastia" (large breasts).

The criteria for insurance coverage of breast reductions are specific to each thrid party payer, so prospective patients are encouraged to review these individually.  The preauthorization departments are fastidious in enforcing them, chapter and verse. 

a) Musculoskeletal:  Physical findings of thoracic kyphosis (dowager's hump) neck, shoulder and upper back strain should be documented by primary care, physical therapy or orthopedic surgery.  Often the patient must have participated in a program of therapy supervised by chiropractors and/or physical therapists, without documented  improvement.

b) Body Mass Index:  Insurance companies usually require that a woman's height and weight conform to "nonobese" Body Mass Index (BMI), < 30.  They argue that musculoskeletal "loading" is a consequence of excess fat mass in the breast, ergo, if a woman looses weight her symptoms will resolve.  A breast is composed of fat, glandular and fibrous tissue, however only the fat component will respond to weight reduction. Prior mammograms, which document "dense parenchma, which limits resoluiton" is usually helpful, as this correlates with a higher percentage of glandular to fatty tissue.  I normally attach the latest result.

c) Resection weight: The insurance requirements for the amount of breast tissue removed generally ranges from 500/750gm/side (average 0.5lbs/side).  By stipulating a high resection weight, the insurance company tries to exclude procedures which are considered "elective" or cosmetic in nature. Breast reduction is on the same continuum with breast lift.  Regrettably, it may oblige a woman to accept a smaller breast volume, if she wants to have insurance coverage. 

d) Family history of breast cancer:  While a breast reduction doesn't allow the surgeon to perform a comprehensive inventory of a woman's entire breast, it does reduce the breast tissue, which is at risk of malignant transformation.  This historical factor may be considered favorably by the reviewing insurance company. 

Ultimately, the symptoms of neck, shoulder and upper back strain resolve almost immediately after surgery and do not recur, unless the woman experiences a "regrowth" of her breasts. Breast development is most prolific at three times of life: a) puberty; b) pregnancy/lactation; c) menopause.  The common denominator is hormone fluctuations, which are the driving force for breast development.