Breast Reductions and Insurance: What You Need to Know
Updated: Sep 26
A Breast Reduction can be a truly life-changing procedure for patients suffering from the physical and emotional burden of large breasts (macromastia). The physical symptoms generally relate to the sheer weight of the breasts and include back/neck/shoulder pain, rashes under the breast, shoulder grooving, headaches and upper extremity numbness. The psychological effects, however, are undeniably as devastating as the physical symptoms we as practitioners tend to concentrate on. Shame, unwanted sexual attention, inability to find clothes or bras that fit, and embarrassment all have a significantly detrimental effect on a woman’s self-esteem and body image, especially during those delicate years of most rapid breast growth.
While those who are desperate for relief from excessively large breasts might jump at the chance to have insurance cover their procedure, it wouldn’t be the insurance game if there weren’t some hoops to jump through or some potential tradeoffs to consider.
Before pursuing insurance approval for a Breast Reduction, there are a couple of must-know details you should review.
Documentation of Symptoms
So what exactly are the “hoops” we need to jump through? The first hoop is to document, document, and document ALL of your symptoms. Get rashes under your breasts? Go see your PCP for treatment. Have chronic neck pain? See a Chiropractor. Insurance companies want surgery to be a last resort. So, the better case you can build as to just how concretely impactful large breasts have on your quality of life and physical health, the more likely they are to deem it medically necessary and grant approval.
The Schnur Scale
So you’ve appropriately documented all the symptoms directly related to your breasts, now what? Well, next you come in to see me! We will take careful measurements, photograph the evidence, and get an accurate height and weight. From here, this is where things get a little murky. The standard way that insurance companies have typically determined the “medical necessity” of a breast reduction is with the help of something called the Schnur scale (or some variation of it). Basically, this scale was developed to determine the weight of breasts that are believed to benefit from a reduction. We take your height and weight, calculate your body surface area, and then plug this value into the scale. The formula then determines the minimal amount of grams that the insurance company will require me to remove in surgery in order for them to cover the costs.
As you can imagine, this “one-size-fits-all” approach is problematic on many levels.The two most important problems are that it completely disregards any psychological or emotional symptoms the patients may experience, and that its a system based on weight (in grams) while the typical language we use when it comes to breasts is volume. Do volume and weight correlate? Well,yes but often not in a consistent or palatable way. Some breast tissue is dense and fibrous, some more fatty. For the same volume, these might have very different weights.
Where It’s Tricky
For patients with very, very large breasts, the weight requirements imposed by insurance companies are no big deal, as we will be removing well over the required minimum. I see a lot of patients, however, who fall into a grey zone. Their breasts are large, yes, but the minimum required tissue removal very well may just take them to a cup size they won’t be happy with or may not be proportionate with. Even further, when I am struggling to remove enough tissue in the operating room to satisfy the insurance company requirements, I no longer get to consider the shape of breasts in what I remove and what I keep. These conversations are very challenging to have with patients because I only have my best estimate as to what volume a particular weight will translate to. What I can say, without a doubt, is that there is no guarantee of the final cup size the patient will end up being.
Ultimately, dealing with insurance companies is always a bit of a gamble. What’s most important is that patients understand the inability to determine final cup size preoperatively, and also that they are willing to accept a shape or size they might not consider “ideal” in cases where the amount of tissue required to be removed is high compared to the overall breast volume.
For more information on Breast Reductions or any other procedure Dr. Megan performs, please visit her website www.drmeganmd.com. Schedule your consultation today by calling 206.860.5582.