The short answer is yes, insurance may cover at least a portion of the cost of a breast reduction, particularly when your surgeon, primary care physician, and insurance company deem it medically necessary. (1)
At ME Plastic Surgery in Manhattan, board-certified plastic and reconstructive surgeon Dr. Marc Everett and fellowship-trained plastic and reconstructive surgeon Dr. Ruya Zhao prioritize patient health and safety while achieving transformative results. Dr. Everett and Dr. Zhao work closely with each patient to customize treatment plans that align with their goals. Alongside their dedicated administrative staff, they are experienced in navigating the complexities of insurance coverage for medically necessary procedures.
To explore your breast reduction options and to learn more about the insurance process, call (212) 774-7715 or submit our online contact form to schedule a personal consultation.
Contents
About Breast Reduction
Breast reduction removes excess breast fat, glandular tissue, and skin from the chest to achieve a breast size more proportionate to the patient’s body. The goal is not purely aesthetic; the procedure can alleviate the physical challenges of overly large breasts. Symptoms such as chronic back, neck, and shoulder pain, skin irritation, rashes, deep bra strap indentations, and persistent headaches can significantly impact physical mobility and quality of life. (2)
Dr. Everett and Dr. Zhao perform this outpatient surgery with the patient under general anesthesia. They use an anchor (inverted-T) incision to remove the excess tissue and reposition the nipple and areola. The recovery period typically involves a few weeks of restricted activity, but the relief from chronic pain and the improvement in body image are often immediate and life-changing.
The Schnur Scale
The Schnur Sliding Scale correlates the weight of breast tissue to be removed during a breast reduction with the patient’s total body surface area (BSA). It defines three categories: those with medical indications for operation, those who merit review, and those for whom surgery could be considered cosmetic. While considered prohibitive to some symptomatic patients, the scale provides a measurable standard that some insurance companies use to evaluate claims. For instance, patients with a larger BSA may need more tissue removal to meet the “medically necessary” threshold than patients with a smaller BSA. Despite its drawbacks, it is a useful metric for patients and clinicians to reference when preparing a preauthorization request.
When Insurance Covers Breast Reduction
Insurance coverage for breast reduction is almost exclusively dependent on proving medical necessity. Insurance providers must deem it essential for treating a verifiable medical condition, not simply to provide aesthetic enhancement. While every insurance policy is different, most major carriers in New York have specific criteria.
Symptomatology
The patient must document persistent, severe symptoms that are a direct result of macromastia. These symptoms often include:
- Chronic pain in the neck, back, and/or shoulders lasting for at least six months.
- Compressed nerve(s) or other neurological symptoms.
- Recurrent intertrigo (skin rash, infection) at the inframammary fold that resists topical treatment.
- Deep bra strap grooves that require extra padding or other modification.
Failure of Nonsurgical Treatment
In some cases, patients may have to prove that attempts at conservative treatment over a specific period of time (usually 3-6 months) have proven unsuccessful. These attempts may include:
- Physical therapy.
- Chiropractic care.
- Use of specialized support bras.
- Pain management medications.
- Dermatological treatment for skin issues.
Minimum Tissue Removal
Some insurance companies require the plastic surgeon to estimate the minimum amount of tissue to be removed from the breasts. This is often where the Schnur Scale comes into play, requiring a specific amount of tissue removal based on the patient’s overall size.
Body Mass Index (BMI)
Some insurance plans require patients to be below a certain BMI to qualify for the breast reduction procedure, asserting that they should attempt weight loss before surgical intervention. This requirement is controversial and not universally upheld. Whereas most surgeons will not take on patients with a BMI higher than either 32 or 35, the surgeons at ME Plastic Surgery practice with an expanded indication for BMI requirements. Because of their extensive experience and solid track record of demonstrating safe outcomes, Dr. Everett and Dr. Zhao will perform breast reduction on patients with a BMI up to 38, and in select cases up to 40. You must be evaluated by one of the surgeons to determine candidacy.
Thorough documentation from the primary care physician, chiropractor, dermatologist, and/or physical therapist, in addition to Dr. Everett’s and Dr. Zhao’s support, can strengthen the case for medical necessity.
The Insurance Process for Breast Reduction
Securing insurance coverage for breast reduction can be a complicated and time-consuming process. Breaking it down into manageable steps can help alleviate stress and make it easier to navigate smoothly.
Personal Consultation and Documentation
During your personal consultation with Dr. Everett or Dr. Zhao, they will conduct a physical exam, discuss your symptoms, and learn your medical history. With their support, you will be able to compile all necessary medical records documenting the history and duration of symptoms and other remedies you have tried.
You will submit a formal request for coverage to your insurance company that contains a comprehensive packet of documents, including:
- Surgeon’s Letter of Medical Necessity: A letter from Dr. Everett or Dr. Zhao that explains why breast reduction is medically necessary and includes an estimated amount of tissue to be removed.
- Supporting Medical Records: Documents from other healthcare professionals, if indicated, including general practitioners, chiropractors, etc.
Review and Decision
The insurance company’s medical reviewers (typically nurses and/or physicians) will review the request and supporting materials against their specific coverage policy criteria. This review period can take anywhere from a few weeks to several months. The insurer will then issue a decision: approval, denial, or a request for additional information. Nearly all of our patients are approved on our first request, but at times, we do see that the insurance carrier will deny the initial preauthorization request and require additional documentation or a peer-to-peer review between our surgeons and the insurance company’s medical director. If the denial is upheld, patients have the right to appeal a denial at two levels:
- First-Level Appeal: You can submit a formal appeal, often with a more detailed letter, additional medical records
- Second-Level/External Appeal: If the internal appeal is unsuccessful, you can request an external review, often conducted by an independent third-party reviewer selected by the New York State Department of Financial Services (DFS). This external review is often the final and most powerful option for overturning a denial.
Dr. Everett, Dr. Zhao, and the supportive staff at ME Plastic Surgery dedicate themselves to assisting patients through every phase of this process, understanding that persistence and meticulous documentation are often the key to getting the help you need.
Cost of Breast Reduction in New York City, New York
The total cost will depend on several factors, including anesthesia fees, facility fees, and pre-operative tests. If the procedure is deemed medically necessary and covered by insurance, the patient is responsible only for standard out-of-pocket costs, such as deductibles and co-payments. Many covered patients can proceed with their breast reduction, incurring minimal or no out-of-pocket costs.
To start mapping your path toward breast reduction, call the ME Plastic Surgery office at (212) 774-7715 or submit an online contact form.
FAQ
Will insurance cover a breast lift?
Generally, a breast lift is considered a purely cosmetic procedure and is not covered by insurance. Dr. Everett says, “Every reduction is a lift, but not every lift is a reduction.” While a reduction often results in a “lift” as a procedural byproduct, the insurance coverage is based solely on the need to remove mass for medical reasons, not the aesthetic improvement. How much tissue removal is necessary to qualify for coverage? While some metrics, like the Schnur scale, suggest a minimum amount, each insurer has its own guidelines. What is most important is that Dr. Everett and Dr. Zhao document that they will remove a “significant” amount of tissue and that they expect removal to alleviate the chronic medical symptoms.
What happens if Dr. Everett or Dr. Zhao deems my surgery medically necessary, but my insurance request gets denied?
Dr. Everett, Dr. Zhao, and their team will initially set up a peer-to-peer review with the insurance carrier’s medical director to attempt to overturn the decision. If this attempt does not prevail, they can provide you with additional information to help you draft your appeal. If the internal appeals are denied, New York State law allows an external review by an independent third party, which often has a high success rate in overturning denials.
References
- Perdikis G, Dillingham C, Boukovalas S, Ogunleye AA, Casambre F, Dal Cin A, Davidson C, Davies CC, Donnelly KC, Fischer JP, Johnson DJ, Labow BI, Maasarani S, Mullen K, Reiland J, Rohde C, Slezak S, Taylor A, Visvabharathy V, Yoon-Schwartz D. American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty. Plast Reconstr Surg. 2022 Mar 1;149(3):392e-409e. https://pubmed.ncbi.nlm.nih.gov/35006204/
- Pocock KS, Laikhter E, Hardy BW, Holtzman-Hayes N, Strauss LD, Pavlovic JM, David LR, Katz AJ, Kumar S, Pestana I, Calder B, Nye BL, Duet M, Wells RE. Enlarged Breast Size (Macromastia) and Associated Neurologic Risks: A Scoping Review. Neurology. 2024 Aug 13;103(3):e209660. https://pubmed.ncbi.nlm.nih.gov/39013127/
- Boyd CJ, Hemal K, Cohen JM, Daar DA, Gwin J, Zupko K, Karp NS. Preauthorization Inconsistencies Prevail in Reduction Mammaplasty. Plast Reconstr Surg Glob Open. 2023 Oct 26;11(10):e5361. https://pmc.ncbi.nlm.nih.gov/articles/PMC10602495/