Breast Reduction Covered by Insurance

Q: How can I get my breast reduction covered by insurance????

Breast reductions are a life changing procedure for most patients. Not only do you get the cosmetic improvement of smaller, proportionate, and perky breasts, many patients have lasting improvement in neck pain, back pain, and headaches. Even small breast reductions can have symptom improvements due to the change in your body’s center of gravity by moving the breast up to a better position on your chest.

Any woman who wants a breast reduction can have one. Women with smaller, non droopy breasts can sometimes just have liposuction.  Women with larger, droopy breasts have a classic breast reduction. Liposuction is unfortunately not covered as a form of breast reduction for any insurance plan at this time. A classic breast reduction sometimes can be, the key is meeting your plan’s criteria.

Every insurance plan is different, but the first step is to check and see if breast reductions are a covered benefit. Usually it is, but unfortunately there are some plans that do not cover a reduction under any circumstance. I encounter these plans a few times a year 🙁.  If your plan states it is a covered benefit, that doesn’t mean that it will be covered for you. You need to be able to check all their required boxes.

1. “Conservative” Measures

The first box to check is that you have tried “conservative” measures. This means you have tried good bras, exercise, stretching, and over the counter pain medications. I have never met a woman with large breasts who hasn’t tried all of these things. Your surgeon will state this in your consultation. There is no medical evidence that these things work, but it is a requirement for insurance coverage.

2. “Schnur” Criteria

As a general rule, you usually need to remove about 500g (about 1 pound) of breast tissue per side. For scale, a soda pop can is about 355g. Sadly, if you can’t meet this number, your procedure will not be covered. It is unfortunate, but your symptoms’ severity is not considered by insurance plans currently. Plastic surgeons, and Dr. Schnur himself, do not agree with how insurance companies have used this scale, but unfortunately it is what it is.

The Schnur Sliding Scale
The Schnur Sliding Scale

3. BMI Requirements

The third box is only present with some insurance plans. This is a BMI requirement. Many plans require that you have a body mass index that is less than 35, some less than 30. This is important as well for surgical safety.

4. Treat Your Symptoms

The fourth and final box is not always present either. Some insurance companies require you to be seen by a doctor other than your plastic surgeon for a time period to treat your symptoms. Sometimes also seen by a physical therapist. If you have already done this, it is helpful to bring documentation to your consultation with your plastic surgeon.

Once you meet with your plastic surgeon, their office will typically send off what is called a pre-authorization for surgery. This is basically a request for the procedure to be covered. It can take anywhere from 2 days to 2 weeks to get an answer. If your procedure is “covered” or approved, that does not necessarily mean it is free. You will still be responsible for deductibles, co-insurance, or other additional costs. Make sure you speak with your doctor’s office and try to get an idea of what these costs will be so you are prepared.

Although the process seems overwhelming and confusing, plastic surgeons that do many breast reductions can help you navigate it without too much stress.  We will do everything to help you get your breast reduction covered by insurance!

Here is a link to a useful body surface area calculator!

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