A breast reduction shrinks more than just one’s cup size—it diminishes neck, back, and shoulder pain; abates rashes beneath the breasts; minimizes discomfort during exercise; and even decreases anxiety, depression, and body-image dissatisfaction, research shows. Despite the physical and psychological perks of the procedure, insurance companies still consider it a cosmetic undertaking until patients prove the operation to be medically necessary—a process that one recent study described as “cumbersome and potentially controversial.” what makes a breast reduction medically necessary and does insurance cover breast reduction for back pain
According to that same paper, published in Plastic and Reconstructive Surgery (PRS) in 2020, preauthorization denial rates for breast reduction surgery are on the rise—and have been increasing steadily over the past five years, for a variety of reasons, and particularly among private carriers. Insurance coverage criteria, the authors note, “are used arbitrarily, without scientific evidence, and are inconsistent with clinical practice”—which can make it tricky for a patient to build their case when aiming to get the procedure approved.
How Hard Is It To Get Insurance To Cover Breast Reduction
We asked top plastic surgeons how to gather the evidence needed to satisfy typical insurance requirements—and how winning coverage can change the rules of a breast reduction.
What are the criteria for coverage of a breast reduction?
When seeking preauthorization for a breast reduction, your goal is generally twofold. You first need to demonstrate that the procedure is “medically necessary and therefore reconstructive rather than cosmetic,” says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. According to Dr. Amaka Nwubah, a board-certified plastic surgeon in Nashville, Tennessee, insurance companies tend to define “medically necessary” as “impacting someone’s physical health, in the form of back pain—upper back pain is seen as more related to the breasts than lower—neck pain, and shoulder pain that significantly affect their quality of life and their ability to function.”
You may also need to show that “conservative medical management” has failed to improve your situation, adds Dr. Mahmood. The so-called conservative therapies patients are frequently expected to try before surgery include physical therapy and/or chiropractic care for posture and pain issues, dermatologic treatment for recurrent rashes related to breasts rubbing and occluding the skin, and DIY remedies like oral pain relievers and special bras.
But before exploring any of that, you’ll want to review your policy, to ensure breast reduction surgery (aka “reduction mammaplasty”) isn’t on the list of coverage exclusions. Assuming it’s not, your policy will outline precisely what constitutes a medically necessary breast reduction, who qualifies for the procedure, and the exact criteria for obtaining coverage. While stipulations vary by insurance carrier and plan, many request the following.
- Photographic documentation of “breast hypertrophy” or overgrowth. Standardized photos are usually taken by a plastic surgeon, at the time of consultation.
- Persistent symptoms, in multiple areas of the body, that are directly caused by heavy breasts and have occurred for a specified length of time (typically at least one year). Beyond breast-associated musculoskeletal aches, “they look for symptoms such as shoulder grooving, skin rash or irritation, nerve injury, and restricted activities,” says Dr. Ran Stark, a board-certified plastic surgeon in Bryn Mawr, Pennsylvania.
- Pain that fails to improve after a monthslong trial period of nonsurgical treatments, such as NSAIDs and muscle relaxers, physical therapy, dermatologic care, orthopedic evaluation, medically supervised weight loss, and support bras with wide straps. These interventions, it’s worth noting, have not been found to deliver long-term relief for those with symptomatic breasts.
- The estimated weight of tissue the surgeon will remove from each breast, based on the patient’s body surface area. “Insurance companies calculate how many grams of breast tissue must be removed for the procedure to be considered medically necessary,” Dr. Mahmood explains.
- A statement from a plastic surgeon, testifying that the patient’s symptoms are due to overly large breasts and that a breast reduction will likely improve them.
In Dr. Nwubah’s experience, not every policy asks patients to check every box. “I have seen some insurance companies cover breast reductions based on my note and photos alone,” she says. “Every insurance company is different—but at the very least, a patient needs to have symptoms documented by their primary care provider.”
How can patients build a case for coverage?
As a first step, reach out to your primary care physician, to get your breast-related symptoms on the record and ask for referrals to providers who can assess and possibly try to treat those issues. “We recommend that patients establish care with a physical therapist, chiropractor, or orthopedist so there is documentation that they have sought medical management for their neck, back, and shoulder pain—and that these conservative treatments did not provide sufficient improvement in symptoms,” says Dr. Mahmood. Additionally, “they often need a note from a primary care physician, dermatologist, or gynecologist, reiterating their long-standing history of symptoms, including rashes in the breast folds.”
It helps, Dr. Mahmood adds, if you’ve maintained a consistent weight over time, as this “demonstrates that [large breasts] are not due to recent weight gain.” For women over 40, she also suggests getting a mammogram, if you haven’t had one recently, to avoid scheduling delays if and when your carrier greenlights your breast reduction.
When it comes time to meet with a plastic surgeon, check to see if your insurance plan limits you to in-network providers or allows you to see the surgeon of your choice. You’ll also want to confirm that your preferred physician takes insurance; not all do.
During your consultation, your plastic surgeon will take a complete history and perform a physical exam. “I document patients’ complaints of neck and back pain not alleviated by physical therapy/chiropractic treatments, painful grooves in their shoulders from bra straps, rashes under their breast folds that sometimes require prescription topical treatments, difficulty finding clothes that fit, and difficulty working out and doing daily activities, due to their excessively large breasts,” says Dr. Mahmood. Your surgeon’s team will also take photos of your breasts from various angles and record your current height and weight.
Your surgeon will then write a note, detailing their findings and the minimum amount of tissue they anticipate removing, and submit it to your insurance carrier, along with your photographs and supporting letters from other healthcare providers in order to “create a comprehensive case for why a breast reduction is medically necessary and is being requested,” says Dr. Mahmood.
How often do breast reductions get covered by insurance?
In the aforementioned PRS study, researchers reviewed 295 preauthorizations and found that 72% were approved. In both Dr. Nwubah’s practice and Dr. Mahmood’s, about 80% of breast reductions are covered by insurance. Dr. Mahmood credits her insurance manager with achieving the high success rate, noting that “it’s very important to find a plastic surgeon who does a lot of breast reductions and whose team has experience with different insurance carriers and knows the ins and outs of every carrier and their individual plans, as plans within a carrier can differ greatly.”
What Makes A Breast Reduction Medically Necessary
Insurance carriers deny coverage for a variety of reasons, ranging from commonsense stuff, like contract exclusions and out-of-network physicians, to more frustrating factors, like spotty documentation; proposals to remove too little tissue; or failure to meet some element of the carrier’s criteria, such as not devoting ample time to alternative treatments—six months of physical therapy, say.
Perhaps the most controversial aspect of the approval process pertains to insurers’ reliance on the Schnur Sliding Scale, which calculates a patient’s body surface area, based on their height and weight, in order to “determine the amount of breast tissue that should be removed, to have a medically significant benefit,” Dr. Nwubah explains. Sometimes this number can “bring a patient, essentially, down to nothing,” she adds. “I find most patients still want to have breasts that fit their frame—they just don’t want them to be as heavy. Insurance doesn’t seem to make this connection, unfortunately.”
And this doesn’t sit well with some surgeons. “In my practice, I do not not perform breast reduction under insurance,” Dr. Stark tells us. In his opinion, operating according to Schnur math “can result in a breast that is not cosmetically ideal and [one that is], usually, too small for the patient,” he says. “When I approach a breast reduction, the goal is to remove the appropriate amount of tissue, to create a smaller but well-shaped and -positioned breast. The result should not be about weight but achieving the best-shaped breast for the patient.”
Of course, aesthetics isn’t a variable in the “medically necessary” equation—and this isn’t surprising. What experts do find perplexing is that the majority of carriers continue to use the Schnur scale (or a version of it) despite numerous studies in the plastic surgery literature finding zero correlation between the volume of tissue removed from a patient’s breasts and the symptom relief they experience post-op. A 2015 paper, for instance, concluded that “reduction mammaplasty has a positive impact on a range of symptoms, even with lower-volume resections and regardless of body surface area–calculated adjustments.”
Does Insurance Cover Breast Reduction For Back Pain
If your breast reduction gets approved, your insurance company will cover the cost of your surgery, assuming you don’t deviate from the pre-approved plan: you must have the mandatory number of grams of tissue removed from each breast, by an in-network physician, at a facility that participates in the particular plan for which you’re covered. “All insurance-based procedures are performed in a hospital, generally,” Dr. Nwubah says. “If a private OR is accredited with insurance, then it can be performed there.”
As proof that sufficient tissue is, indeed, removed, surgeons weigh the resected tissue from each breast and record the grams per side in the operative report.
The bottom line: plastic surgeons, on the whole, find insurance criteria for covering a breast reduction to be largely outdated, unfounded, and limiting. But if you choose a surgeon whose team has mastered the preauthorization process, you stand a good chance of getting the procedure paid for. Before moving forward, however, you’ll want to carefully consider your carrier’s terms and discuss any cosmetic concerns with your surgeon so that your downsized breasts look every bit as amazing as they make you feel.