It is not mysterious as to what makes a breast reduction medically necessary as most health insurance carriers have a very specific list of requirements. In fact, it is one of the most scrutinized of all plastic surgery procedures covered by insurance. There are several important issues including your weight and breast size, how much tissue the plastic surgeon plans to remove, documentation of painful symptoms, and what other non-surgical treatments have you had.



Your body weight is an important consideration. if you are over 20% of your ideal body weight, your insurance company may say you need to lose weight first. We all know that weight loss will not decrease the size of your breasts (it some cases it may make the skin sag more, causing greater strain on your neck, shoulders, and back), nevertheless, this is a criteria that insurance companies use. At the least, if you are overweight, attempts at weight loss must be done and documented. If you can only lose so much weight, then so be it. But some weight loss effort may be required.

Breast size is an obvious important criteria. There is no precise breast size that makes the cut-off for insurance coverage. Rather it is a combination of your height, weight, and breast size. Technically, your height and weight are put into a formula to create your BSA. (body surface area) Based on your calculated BSA and the amount of breast tissue your plastic surgeon says will be removed (there is an industry standard graph and table which determines this) is the numerical determinant for medical eligibility. The amount of breast tissue your plastic surgeon says he will remove is an estimate but that submitted number is of critical importance. The whole concept of this numerical determinant is for the insurance company to determine that they are not really paying for a breast lift which is mainly a cosmetic operation. I call this compensation for the 'sins' of the past done by plastic surgeons from decades ago.

One of the hardest criteria to document, but is one of the big three, is what have you done non-surgically that may make your breast and body pain go away without surgery? We all know that nothing short of reducing large breasts will make their symptoms go away, but again, we must play by their rules. Some form of physical therapy, chiropractic treatment, or even acupuncture must usually be tried first (for three months) and documented that it did NOT work. Most breast reduction consults that I see are usually lacking in this criteria of eligibility. It may feel like a waste of the insurance's money and your time, but it often must be done.

To determine possible medical coverage, your plastic surgeon will take photos and measurements of your breasts and bundle up all of the information listed above and send it to your insurance company. The more complete this information is, the less likely you will get a letter (4 to 6 weeks later) that says there is not enough information to make a predetermination. Your breast reduction may be determined to be medically necessary if you meet all the required criteria! It can be a slow process, and it may take more than one letter from your plastic surgeon, but persistence and perseverance is the key to a medical necessary breast reduction.