Breast reduction surgery is one of the most common procedures performed by US plastic surgeons and has been shown to be effective in reducing the symptoms and improving the quality of life for women with heavy, pendulous breasts. In fact, The American Society of Plastic Surgeons reported more than 103,000 breast reduction procedures in 2013.
If you have neck and back pain, painful shoulder grooving from bra straps, headaches, difficulty purchasing clothing, and difficulty participating in sporting activities, you may be an excellent candidate for what is called a “medically necessary” breast reduction procedure. Most insurance companies cover this procedure. However, each carrier uses different criteria to determine whether breast reduction surgery will be covered at all.
If you are considering breast reduction surgery, first read your insurance policy. If your insurer does not provide coverage for a breast reduction, you may not even be covered for a consultation with a plastic surgeon to discuss your options. Most insurance companies will look at a woman’s reported symptoms, the duration of her symptoms and how these symptoms may have affected her quality of life. It is important for you to discuss your concerns with your primary care physician and to have your symptoms documented in your medical record. Letters from your primary care physician, chiropractor and/or physical therapist can be invaluable “evidence” in building your case for prior authorization for a breast reduction. This documentation, when included in a packet with a letter and pictures from your plastic surgeon, will help you obtain authorization from your insurer prior to scheduling surgery. This is a necessary step, as an insurance carrier may refuse to cover the costs associated with surgery if the procedure is not authorized beforehand.
It is common for insurance companies to require that a certain amount of breast tissue be removed from each breast in order for your breast reduction to be considered medically necessary. The breast tissue weight to be removed (for insurance approval) is determined based on your height and weight, but often this weight requirement is in conflict with a woman’s aesthetic goals. Insurance companies are not concerned with the way you look, despite the well-known fact that physical appearance can have an impact on quality of life. Despite medical literature proving that breast reduction surgery improves a woman’s quality of life regardless of the weight of tissue removed (Spector & Karp, 2007), a recent report by Koltz, Frey and Langstein (2013) revealed that 86 percent of surveyed insurance providers still use a chart based on the 1991 Schnur Sliding Scale that compares a woman’s motivation for breast reduction and her weight.
The Schnur scale recommendations are derived from a survey that asked plastic surgeons their perceptions of whether their patients’ motivations for a breast reduction were reconstructive or cosmetic (Schnur et al., 1991). A survey (even one among surgeons) should not be taken as scientific proof. Years later, Schnur himself even challenged insurance carriers’ misuse of the scale and indicated that the scale should no longer be used as criteria for insurance coverage (Schnur, 1999).
Each person responds differently to physical symptoms and breast reduction is not a term that should be defined by a number, but rather needs to be considered within the context of the individual woman seeking a better quality of life. If you disagree with your insurance carrier’s decision, you are entitled to an appeal.
Being a good candidate for a surgical procedure also means you have a thorough understanding of the condition that is being treated and of the intended procedure. Breast reduction is one of the most patient pleasing procedures we perform. If you feel that large breasts are interfering with your daily functioning, ask to visit with at least one plastic surgeon certified by the American Board of Plastic Surgery to learn about your options for breast reduction. Your family, your personal physician and your experienced plastic surgeon can help you make the decisions that are right for you.