What would qualify as medically necessary for a breast reduction?

Breast reductions are usually considered medically necessary when you meet certain criteria. Each company will usually have slightly different criteria and you can usually find these on their website or can be given them by your plastic surgeons office.  Most will require long standing symptoms of back, neck or shoulder pain that is documented by your primary care physician for at least 3 months.  They also want to see if your PCP has tried other methods of treatment before surgery such as NSAIDs, pain meds, physical therapy or chiropractor visits and these failed to alleviate your pain for 3 months or more.  They will also look for posture problems, skin rashes, numbness of your hands, shoulder grooves and more.  They will also look for how many grams of tissue that can be removed from each of your breasts during surgery.  Each company has a sliding scale based on your body surface area called the Schnur scale and usually you must be above the 22nd percentile for grams of tissue to be removed in order to qualify.  These should get you started, Good Luck!

Each Insurance company is going to have their own criteria for this. Some of these are back pain, neck pain, shoulder pain, breast pain, bra strap grooving, intertrigo, postural changes, and others. Perhaps most importantly, they have tables which match your body surface area to expected excision weight. If the surgeons best estimation is that he will remove a certain weight from each breast, and this falls under the company guidelines, you will usually be approved.

Thank you for your excellent question, and I am sorry to hear about your back pain and migraine issues from your large breasts.  Each insurance carrier will have specific criteria that their members will be required to meet in order to have a breast reduction considered medically necessary. Typically, insurance companies will require 3-6 months worth of documentation from your primary care provider of breast-related symptoms (rashes, neck/back pain, and shoulder grooving), and treatment failures (weight loss, physical therapy), that have led you to pursue surgery. Once approved, the insurance companies will determine either a fixed amount of breast tissue, or an amount proportional to your height, that needs to be removed in order to have the operation covered by insurance.   Hope that this helps.

I am sorry to hear about the problems your disproportionately large breasts cause. There is nothing in your description that makes me think that you would be at greater risk of denial of breast reduction surgery coverage by your health insurance company. On the contrary, based on your description, you sound like you may be an excellent candidate for breast reduction surgery; of course, much more information is necessary to provide you with definitive advice

  Generally, the more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.  
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link, helps. Best wishes.

Every insurance carrier and plan is different but, in general, they won't approve a breast reduction for things that they can't measure, like pain.  They will approve a reduction, unless it is a contractual exclusion, for things that they can measure.  For example, if a surgeon well remove 600 grams of breast tissue on a woman who isn't morbidly obese.  Your plastic surgeon can help you determine if you can get insurance coverage for a breast reduction with you specific plan.

In the past, getting a breast reduction approved by insurance was not a big deal.  They have now made it more and more difficult.  In addition to having a required amount of tissue to be removed, they require documentation of conservative measures taken like physical therapy, weight loss etc.  They also typically require documentation from your PCP, a spine surgeon, orthopedic surgeon documenting you don't have other reasons for back, shoulder, neck pain.  There are a lot of hoops to jump through to get this done.  For that reason, a lot of plastic surgeons just don't do Breast Reductions through insurance because of the head ache that they produce.  Your other option is to save up some money, or get a medical loan, and finance the whole thing yourself as a cosmetic procedure.  Not everyone can do this, but depending on your situation it might be all you can do. 

Typically documentation from other physicians in the form of a letter supporting your need for breast reduction surgery is very helpful. Schedule a consultation with a board certified
plastic surgeon. If you do not know of any in your area, ask your OBGYN or PCP
for a list of reputable surgeons. Upon examination, your surgeon will be able
to discuss your specific concerns and recommend a treatment plan that will
address your concerns. The office staff will be able to assist you in
submitting a pre-certification to your insurance. Make certain that your
surgeon is in-network with your insurance plan prior to your consultation. Best
of luck!

Insurance companies are becoming more and more restrictive that many women with overlarge breasts and are suffering from systemic pain and discomfort are excluded.  Fortunately, you can always make an appeal if your claim has been denied.The first step is to find a board-certified plastic surgeon who specializes in breast reduction surgery because his staff is well-verse when it comes to the insurance application process.  They can also present the proper documentation proving that your operation is not just cosmetic, but a medically necessary procedure that will improve the quality of your life. Take note that each issuer has their own requirements, although the list below shows the most common ones:*  Amount of breast tissue to be excised.  For instance, many health insurance issuers require at least 500 grams (per breast) of removed tissue before they cover the surgery's cost. *  Breast size relative to the body.  This means that your height and weight are taken into account.  This is advantageous for petite women because even smaller reductions could be covered with this kind of arrangement.*  Tried other non-surgical treatments.  They may ask you to try therapy or weight loss first before they agree to cover the cost of breast reduction.Good luck and best wishes.