If you experience any neck, back, or shoulder pain, bra strap grooves, skin irritation or infection, poor posture, decreased activity or other functional problems that are related to large breasts then breast reduction surgery may be covered under your insurance. Insurance coverage depends upon specific terms of each policy, and individual patient factors/symptoms.More frequently, however, breast reduction is written as an exclusion in many insurance policies. Patients seeking insurance coverage for breast reduction surgery (performed for symptomatic breast enlargement) must have their plastic surgeon obtain written pre-authorization of medical necessity from the insurance company. Insurance policies vary tremendously in their extents of coverage, requirements, documentation, and exclusions. Most insurance policies have specific requirements for minimum amounts of breast tissue that need to be removed. Some insurance policies require overweight women to lose weight prior to surgery. Still other policies may require an orthopedic evaluation of back pain, or a trial of physical therapy and anti-inflammatory medication prior to authorizing surgery. And, many insurance policies specifically exclude breast reduction surgery, even if it may be medically indicated. Some of these requirements may seem unfair or not make sense, but if these specific provisions are written into a patient’s insurance policy they must be followed if insurance coverage is expected. As all policies differ, it is important to check with your insurance company for the specific documentation you are required to file when seeking a medical necessity determination. Many insurance companies are now requiring that some or all of the following criteria, or other similar criteria, be met in order to be considered allowable for coverage for breast reduction. 1). The patient has significant symptoms, documented in their medical records, which interfere with activities of daily living, including: pain in the upper back, neck, and shoulders which is of long-standing duration and increasing in intensity, and/or Persistent, non-seasonal submammary skin rash/inflammation/irritation (intertrigo) which is unresponsive to local hygiene and topical anti-infective therapy, and/or Ulnar nerve paresthesias resulting in pain and/or numbness in the arms and/or hands. 2). The physical exam must document: Significant shoulder grooving or skin ulceration, and Obvious breast hypertrophy, and Sternal notch-to-nipple distance > 28cm for women > 5’2” tall, or > 25cm for women < 5’2” tall, and Physical exam findings consistent with symptoms related to mammary hypertrophy. 3). There must be a failure of (sometimes documentation is required) a comprehensive conservative treatment measure, including: A minimum of 6 weeks of physical therapy for the back, neck, and/or shoulder pain including a maintenance home exercise program, and Appropriate support bra with weight distributing straps, and Anti-inflammatory medication, unless contraindicated, and Symptomatic measures, including application of heat and cold, and Appropriate local hygiene and topical medication for intertrigo. 4). The documented Body Mass Index (BMI) must be < 30, which is below the level considered “obese” according to the guidelines of the National Institutes of Health (NIH) – National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obese Adults. Following your evaluation, your surgeon would estimate how much tissue needs to be removed; and usually this is discussed during the consultation. Your plastic surgeon would then submit a letter to your insurance company documenting the history and exam findings and request prior authorization for breast reduction surgery. The entire process may take 4-8 weeks before an answer is obtained from the insurance company. If breast reduction surgery is approved –great; I am sure you will feel much better following your surgery. If not, then there is usually a method by which patients can appeal the decision. Breast reduction surgery is considered “cosmetic” (patients pay out of pocket) for those individuals who are asymptomatic or do not meet the criteria for medical necessity set forth by their insurance company. The satisfaction rate following breast reduction surgery, for women who suffer from symptomatic breast enlargement, is very high. Women experience improvement/resolution of chronic aches and pains, and usually have increase freedom of movement and activity. Many say, “I wish I would have done this years ago.” It sounds as if an evaluation for reduction surgery is certainly appropriate for what you describe about yourself. I would recommend you see a plastic surgeon to discuss your options and see if you qualify under your insurance plan. I hope this helps. Best wishes. Ken Dembny