What is the Criteria for a Breast Reduction to Be Medically Necessary?

What degree of back and shoulder problems/pain are considered breast reduction reasons for medically necessary according to most insurance options? How much of the problem is alleviated by such a surgery?

Doctor Answers 12

Criteria for Insurance Coverage.

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Every insurance company has their own set of criteria. Typically they want documentation of back and neck pain, grooving on the shoulders left by bra straps, and they require a certain amount of breast tissue to be removed.

Insurance Companies' Criteria for Breast Reduction Surgery

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Most women who qualify for insurance coverage for a breast reduction suffer from back, neck, shoulder pain, or have recurrent inflammatory conditions under their breasts.  Other symptoms that may help qualify include numbness or tingling in the hands.  Normally the numbness or tingling would be in addition to some degree of back, neck, or shoulder pain.  Grooving in the shoulders from the weight of the breasts on the bra straps are also symptoms that may help qualify a patient for a breast reduction.  Another necessary component is the amount of tissue to be removed.  The amount required varies from insurance company to insurance company.  Some insurance companies will require previous trials of nonsurgical therapy.  These may include physical therapy or a back and spine evaluation to rule out associated back or spine problems.  Normally, these non-medical approaches are unsuccessful.  Breast reduction typically is a very rewarding procedure for the patient and the plastic surgeon.  Normally, when a woman comes to a plastic surgeon’s office with complaints of back, neck, or shoulder pain and recurrent irritation under the breasts, a breast reduction will very predictably solve the problem.

Insurance coverage for breast reduction.

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Insurance Coverage for Breast Reduction

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Criteria for medically necessary breast reduction

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Every insurance company will be different with regard to its rules for a medically necessary breast reduction, and it is necessary to read the fine print in your specific policy to determine eligibility. Often, an insurance company will have a requirement with regard to the number of grams that need to be resected from each breast for the patient's body surface area (BSA). Symptoms that they are often looking for include back, neck and shoulder problems, shoulder grooving, intertrigo (rashes under the breast), and other problems that interfere with activities of daily living. It is often helpful to have documentation from a physical therapist or an orthopedic surgeon with regard to the back, neck and shoulder problems, a history of buying special bras for the shoulder grooving, and prescriptions for special creams from a dermatologist for rashes under the breasts. Most of these problems are alleviated by such a surgery, but the only thing that can really be guaranteed is smaller breasts. For example, if your back problems are actually due to a herniated disc as opposed to the heavy weight of your breasts, then a breast reduction will obviously not fix the herniated disc. This is one reason that some insurance companies want to rule out other causes of common macromastia (large breast) symptoms before approving a medically necessary surgery.

Criteria for Insurance Coverage varies

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Every insurance plan has their own unique criteria on whether they will cover a breast reduction.  More and more, we are seeing plans where a breast reduction is not a covered benefit.  If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage.  Some set the amount in relation to your BMI (height and weight).  Others require extensive medical records documenting neck pain, back pain, and history of rashes.   The other alternative is to opt for a breast reduction as a self-pay option.   Start by visiting with a board certified plastic surgeon to learn more about your options.
Best wishes,

Dr. Basu
Houston, TX

Will My Breast Reduction be Covered?

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Whether breast reduction surgery is covered or not varies from company to company depending the policy whihc might exclude coverage for all, but extremely large breast reductions.

Typically they will request documentation of symptoms such as neck pain and back pain, and photographs, as well as a trial of physical therapy and weight loss, and an anticipated insurance mandiated minimum amout of breast tissue to be removed.

This information will be reviewed and often authorization is denied per routine.  therefore, you should appeal the denial decision and and request another review.  If you follow the appeals process to the end, and you meet their criteria, then you may be approved.

Fredrick A. Valauri, MD
New York Plastic Surgeon

Breast reduction insurance coverage

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It is important to rule out other sources of  neck and back pain prior to proceeding with breast reduction surgery; otherwise you may be disappointed if the symptoms persist despite having had the surgery. If your symptoms are related to large breasts then the chances that you will be please with results of surgery (and the relief of symptoms) are very high.

The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. 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. Make sure you're saying a well-trained/experienced board-certified plastic surgeon. 

Best wishes.

Medically Necessary Breast Reductions

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Although it varies among insurance carriers, most companies require documentation of syptoms (pain in the neck, back, or shoulders and rashes on undersurface of breasts, for example).  Most companies use the Schnur graph to determine the amount of breast tissue which needs to be removed in relation to body surface area.  Many also require a trial of "conservative therapy" which never works in the case of true breast hypertrophy.  As far as resolution of pain, many patients state that they feel the difference in the recovery room and these patients are among our happiest.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Breast reduction: back problems

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Breast reduction: back problems
#Breastreduction is very successful in reducing these problems.Candidates for Breast Reduction surgery are women who wish to have smaller breasts to achieve a more proportional appearance or to alleviate physical discomfort. Breast reduction can correct symptoms from excessively large, heavy breasts that may cause the inability to do certain exercises, or create back, shoulder and neck pain, poor posture, bra-strap shoulder indentations and chafing or rashes under the breasts

Criteria Varies From Carrier To Carrier...

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The criteria for medical necessity for breast reduction varies from insurance carrier to insurance carrier.These criteria are becoming more restrictive with the passage of time.Many insurance companies consider breast reduction a contract exclusion.
Insurance companies that cover breast reduction require that medical necessity criteria be met.These companies require that patients have significant symptoms associated with breast hypertrophy.The vast majority of patients have back pain, neck pain associated with headaches, shoulder pain associated with shoulder grooves and numbness on the inner arms, rashes beneath the breasts and pain within the breasts themselves.These symptoms improve dramatically with breast reduction surgery.
One of the more important insurance criteria is the anticipated amount of breast tissue to be removed.This number varies from insurance company to insurance company.Many insurance companies use weight and height calculations to determine how much tissue should be removed from each breast.In most cases, estimating the amount of breast tissue to be removed is relatively straight forward.In borderline cases it can be very difficult.
Even when these criteria are met, some insurance carriers continue to deny benefits for breast reduction surgery.For these reasons, many patients undergo breast reduction as a cosmetic procedure.
If you’re considering breast reduction surgery, it’s important to consult a board certified plastic surgeon with experience in this area.This surgeon should be able to formulate a treatment plan that addresses your anatomic findings and achieves your aesthetic goals.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.