Do you have any tips for getting insurance to approve a breast reduction?

Most insurance companies don't factor in muscle mass.  Most use some variation of the Schnurr formula which calculates your BSA body surface area, and then each company has a certain number of grams required. In many ways, this is fair to most.  Little tiny women have a smaller grams requirement than big women, but it is somewhat proportional. Ask your plastic surgeon to seek pre-approval for your breast reduction. Most are approved. For the few that are not, you can calculate how much weight you might need to lose to get approval, or with some plans, you might find the requirements too strict.  In some cases, it may make sense to seek a cosmetic, or cash pay rate.  

Thank you for your question.
Make sure you have documentation supporting a necessity for a breast reduction. Shoulder grooving, neck/back pain, etc. Family physician and gynecologist can help out with this. Best wishes!

When seeking insurance approval for a breast reduction, it's essential to be proactive and well-informed, as each insurance plan has its own specific criteria for coverage. Typically, insurance companies require documented evidence of symptomatic macromastia.
*What is symptomatic macromastia?* This condition often results in symptoms such as chronic back, neck, and shoulder pain, skin rashes or irritation underneath the breasts, difficulty finding well-fitting clothing or bras, and limitations in physical activity. Women with symptomatic macromastia may experience significant emotional distress due to the physical discomfort and the impact on their daily lives. In many cases, breast reduction surgery is considered a treatment option to alleviate these symptoms by removing excess tissue, reducing breast size, and improving both physical comfort and overall quality of life. Insurance providers may cover the surgery if it is deemed medically necessary, based on the presence of these symptoms and other documented factors.
*What needs to be documented?* Providers need to build a strong case for medical necessity. This means documentation of failure of conservative treatments, such as weight loss, physical therapy, pain management, and medication for symptoms like neck, back, or shoulder pain. In addition, many plans require a certain amount of tissue removal (usually based on the Schnur Scale which considers body weight, body mass index, body surface area), although this can vary depending on the insurer. It’s important to work closely with your primary care doctor, who can document your attempts at non-surgical treatments and provide a referral for physical therapy, if applicable.
*What’s next?*You should consult with a plastic surgeon who specializes in breast reduction. The surgeon will assess your condition and measure the amount of excess tissue, which is important when submitting to insurance. Often, the surgeon will also provide supporting letters, detailing your symptoms and the need for surgery. It’s also a good idea to gather additional supporting letters from other healthcare providers, such as a physical therapist. By carefully following these steps and ensuring all documentation is thorough, you will maximize your chances of obtaining insurance approval for the procedure.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York