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Insurance Coverage for Breast Reduction

New Jersey Breast Reduction Insurance | NJ Plastic Surgeon

General Guidelines

Each insurance carrier has its own set of guidelines which are used by their underwriters to determine whether or not a patient’s breast reduction is covered under their individual policy. Some carriers use the absolute weight of breast tissue removed as their guide. Other carriers emphasize symptoms suffered by their insureds such as back and neck pain, shoulder strain, skin rashes developing in the skin underneath he breasts or shoulder grooves from the chronic need for a support bra and the weight of the breast within the bra cup. Some or all of these symptoms may be sufficient to qualify a patient for insurance coverage.

My personal opinion on the issue of “medically necessary vs. cosmetic” is that since a woman’s breasts are structures which both serve a physiologic as well as an aesthetic function, the two cannot be separated when considering surgical coverage or performing the surgery itself. One priority cannot be sacrificed in favor of the other. For this reason, I have always felt that the arbitrary minimum weight of breast tissue excision determined by someone at an insurance company who has never examined a patient and has no understanding of the full clinical presentation or symptoms, is a bad idea. Moreover, no surgeon should be guided by a minimum amount of tissue removed from a patient to determine whether the he gets paid or not for his work. This is a serious conflict of interest and has led to many woman undergoing excessive breast tissue removal.

Breast surgery of any type, for any reason whatsoever, must also be a cosmetic procedure. So our goal is to provide relief from the burden of large pendulous breasts while simultaneously creating smaller but attractive breasts. A good “rule of thumb” is that any patient who requires her breasts to be reduced by less than two cup sizes is actually in need of a breast lift (Mastopexy) rather than a breast reduction (Reduction Mammoplasty) and will not be covered by insurance because it is not medically necessary.

How To Determine if Your Insurance Company Will Cover a Breast Reduction

Most major insurance companies provide coverage for breast reduction, but there are several factors which are considered to determine whether you are eligible for coverage.

Your insurance company must first determine whether they consider your breast reduction medically necessary. The terms and guidelines used to determine this may vary between insurance carriers, the state in which you reside and your particular policy. Call us for a free insurance verification today or simply fill out the form below to get started http://www.bcbst.com/providers/calculator.asp

Most insurance companies use a simple, standard calculation which to determine your body surface area or BSA. Height and weight is all that is needed to calculate your BSA. Once your BSA has been established, it is compared to something called the Schnur Sliding Scale.

The Schnur Scale was developed by a plastic surgeon and is used as a method to mathematically determine the medical necessity of a breast reduction. Most insurance companies use the Schnur scale to compare a patient’s body surface area to the amount of tissue recommended for removal to determine if a breast reduction is for medical reasons.

When you come in for your initial consultation, Dr. Rosenberg and his staff will conduct a thorough examination of your condition. During this consult we will determine how many grams of tissue need to be removed to make your breasts proportional to your body and alleviate any health concerns. Next, a dictated report will be submitted to your insurance company for approval. The determination by your carrier may take up to one month, after which a determination as to insurance eligibility is sent to our office. After this determination is made, we can decide how best to proceed with your surgery and what level of coverage for the procedure is being approved by your carrier.

*Disclaimer: Surgical results are not guaranteed and vary greatly from patient to patient.