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

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.

Each breast reduction patient is unique and responds differently to the surgery. Some experience massive relief after only a modest reduction, while others require more tissue be removed to alleviate back and shoulder pain. Proportionately sized breasts shouldn't cause physical problems, so any sort of back, neck, shoulder, or even head pain that can be linked to breast size is cause to at least consider a reduction. Additionally, different insurance plans use different guidelines for approval. Most require documentation of physical symptoms as well as a certain amount of tissue to be removed, based on the patient's height and weight. 

Breast reduction surgery is typically considered medically necessary when it may help to alleviate physical symptoms caused by overly large breasts. Insurance companies have varying criteria, but may approve the procedure if the patient demonstrates the following criteria:
-Symptom Documentation: A history of back, neck, and shoulder pain, as well as shoulder grooving from bra straps, chronic rashes or infections under the breasts, and poor posture.
-Failed Conservative Treatments: Documentation that conservative treatments, such as physical therapy, medication, over-the-counter pain relief, or supportive bras, have not resolved the symptoms.
-Amount of Tissue to Be Removed: The amount of breast tissue to be removed is often a determining factor. Many insurance companies require that a certain amount of tissue (e.g., 500 grams or more per breast) be removed. The criteria vary by insurance provider, and some may require more or less based on height, weight, BMI, BSA, and breast size.
-Pre-Authorization and Documentation: Often, insurance companies will request additional documentation from healthcare providers (such as primary care physicians and physical therapists) that confirms the necessity of surgery.
Breast reduction surgery may often lead to a significant reduction in discomfort, depending on the severity of their symptoms and the amount of tissue removed. There is no guarantee of symptomatic relief or cup size. The reason for this is that neck/back/shoulder pain may be multi-factorial, and not only related to breast size.
It is important to consult with an experienced plastic surgeon who can customize your surgical plan and determine the best technique for you based on your individual anatomy and goals.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

Criteria for insurance coverage will vary from one insurance provider to the next. However, they all typically share a few requirements:-There must be a demonstrated medical need with evidence of the failure of more conservative measures. Patients will complains of back, neck and shoulder pain. The may also note rashes and bra strap grooving of the shoulders. These symptoms have proven resistant to diet/exercise, medical therapy or physical therapy.-They will also typically have requirements for how much tissue is to be resected which is often based upon BSA (Body Surface Area) and the Schnur Scale.As always, discuss your concerns with a board certified plastic surgeon (ABPS).

You will find that coverage of the procedure varies widely from one insurance policy to the next.  Insurance companies look primarily at the volume to be removed and that the patient has not gotten relief with conservative nonsurgical treatments.  Many insurance companies will cover if you have 500 grams of excess breast tissue (about 1 lb) per side and rarely some may
cover as low as 350 grams. However some companies may require a kilo or more.
 This being said before you go forward with surgical procedures the insurance company may
want you to see your primary care physician to see if they have any other recommendations and such as therapy or medications. Many neck and back pain symptoms can be treated very successfully with
strengthening of the spinal supporting musculature.  This requires some
time and effort but may provide a lifetime of benefit.  
Insurance companies usually want to see a record of having been treated by nonsurgical methods for
at least six months and not getting improvement with conservative treatments.
 This usually means that you have tried diet and exercise, medications and
possibly therapy or chiropractic and have not gotten adequate relief.  The next thing to
do is get an exam with a board certified plastic surgeon with a good
reputation. He should be able to perform an exam to tell exactly how much
excess breast tissue you have.  Then the surgeon will write a letter to the insurance company
and see if they will give approval for the surgery. The insurance company will
send both you and your provider a letter with their decision within a few weeks
in most cases.  Many patients are able to get insurance coverage for the
procedure, but if you do not qualify many places offer a significant reduction
in the price for out of pocket cases that are paid in advance.  
I usually expect that patient will get a significant reduction in their upper back and neck pain symptoms. I hope to get an improvement of 20-80% relief of their pain.  However, some patients get complete relief and some get very little change.  If you find that your symptoms are mediated by wearing a really good supportive bra then I think you have a chance at a higher level of improvement in your symptoms.  Best of
luck on your journey

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

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.

Most insurance companies determine eligibility by how much tissue is to be removed, usually a minimum of 500 grams per breast. Usually a woman needs to be a DD or larger. Then the insurance company wants to know if having large breasts is causing back, neck and shoulder  pain. they want to know what measures you have tried so far to relieve these symptoms, i.e. physical therapy, good support bras etc. Your surgeon will know how to request pre-authorization.Good Luck.

Great question. Breast reductions are often covered by insurance. Typically, the insurance companies look at your height and weight and the estimated breast tissue to be removed as a starting point. The more breast tissue that is going to be removed in weight the more likely you are to get approved. Additionally, patients should be symptomatic: back pain, rashes, wounds, hidradenitis, etc. and idally have tried therapies to improve the condition, such as physical therapy, over the counter medications, antifungal creams, etc. Lastly, most insurance companies require at least one or two letters from your other physicians saying that they think you would benefit from a breast reduction.
-Dr. David Mattos, New York Plastic Surgical Group

The criteria to deem this surgery medically necessary will vary based on insurance plan.  Most will want to see failed conservative treatment for neck, back and shoulder pain.  In addition they will have a formula to determine how much breast tissue will need to be removed based on your height and weight.  If find this to be one of the more life changing procedures I perform.  This can significantly improve a woman's self esteem and help alleviate pain and discomfort from the weight of the breasts.  Make sure to choose a Board Certified Plastic Surgeon to perform your surgery.  Their office should know what your insurance company will require.  Good Luck!