Is a Breast Reduction Covered by Insurance?
If a patient has been diagnosed with breast cancer that has been treated by mastectomy (either complete or by lumpectomy), breast reduction of the non-affected breast to restore symmetry is considered medically necessary and covered by insurance. However, in all other circumstances, breast reduction and panniculectomy are considered cosmetic unless documentation is provided to prove medical necessity.
Medical criteria to determine medical necessity for breast reduction vary among different insurance carriers, but in general medical documentation for breast reduction must demonstrate ALL of the following:
- Significant symptoms that interfere with normal activities, including at least one of the following:
a) symptomatic neck, back or shoulder pain not related to other causes (e.g., poor posture, acute strains, poor lifting techniques). Documentation of evaluation and treatment of neck, back or shoulder pain must be supplied.
b) clinical, non-seasonal submammary intertrigo
- The patient’s physical exam documents at least two of the following:
a) significant shoulder grooving
b) physical exam indicates obvious breast hypertrophy that is consistent with symptoms precipitating request for reduction mammaplasty
c) suprasternal to nipple measurement of greater than 28 cm for individuals greater than or equal to 5’ 2″ tall, or 25 cm for individuals less than 5’ 2″ tall.
d) Failure of conservative measures including:
i) for back, neck, or shoulder pain, failure of 6 weeks of conservative treatment, including all of the following:
(1) appropriate support bra and
(2) NSAIDS (if not contraindicated) and
(3) exercises and heat or cold application
(4) For submammary intertrigo, 6 weeks of conservative treatment, including all of the following:
(a) appropriate hygiene and
(b) appropriate medical/pharmacologic treatment, and
(c) utilization of an appropriate support bra
- Some insurers, BCBS for example, specify a maximum body mass index (BMI) of 27 before breast reduction is considered medically necessary. In situations in which a person’s BMI is greater than the threshold, a documented medical weight loss program is a prerequisite.
When scheduling an initial consultation for possible breast reduction surgery, please provide all medical records documenting prior treatment for symptoms related to breast hyperplasia. Such records will be necessary to prove the medical necessity to your insurer.
Unlike commercial insurance plans, Medicare does not have a mechanism to determine in advance if a breast reduction, unless there is a prior diagnosis of breast cancer, will be considered medically necessary. This decision is only made after surgery has been performed. For this reason, we consider a breast reduction performed for a Medicare recipient without a prior diagnosis and treatment of breast cancer to be cosmetic.