If you’ve been struggling with the physical and emotional burden of overly large breasts, you may be wondering whether a breast reduction is right for you, and more importantly, whether your health insurance will cover it. Candidacy for insurance-covered breast reduction depends on several factors, including your symptoms and medical history. Dr. Frank Lalezar in NYC helps patients determine eligibility and secure coverage for this life-changing procedure.
Is breast reduction covered by insurance?
Breast reduction surgery can be covered by insurance, but only when it’s considered medically necessary. While cosmetic reasons alone typically don’t qualify, insurers may approve the procedure if you’re experiencing chronic pain, skin issues, or functional limitations caused by large breasts. Each insurance provider has its own criteria, and the approval process can involve multiple steps, including documentation, imaging, and pre-authorization.
Working with an experienced surgeon like Dr. Lalezar can help you meet these requirements and increase your chances of approval.
Factors that determine your candidacy for insurance coverage for breast reduction
Chronic pain and physical symptoms
If you experience persistent back, neck, or shoulder pain that interferes with your daily activities, your case may qualify for insurance-covered surgery. Documentation from your physician, physical therapist, or other specialists can strengthen your claim.
Shoulder grooving from bra straps
Visible indentations in your shoulders caused by bra straps are a common sign of breast weight-related stress. Insurance companies may view this as supporting evidence of the physical toll your breasts are placing on your body.
Skin rashes and irritation
Rashes, infections, or other skin issues in the fold beneath your breasts (intertrigo) can indicate medical necessity. These symptoms should be documented by a dermatologist or primary care provider to support your insurance claim.
Failed conservative treatments
Insurance carriers typically require you to try non-surgical methods, like physical therapy, weight loss, anti-inflammatory medications, or custom bras, before approving surgery. Keep detailed records of your treatment attempts and their outcomes.
Minimum tissue removal requirements
Many insurers require a minimum amount of breast tissue to be removed (often 500+ grams per breast), based on your height, weight, and surface area. This is often determined using the Schnur Sliding Scale, which Dr. Lalezar can calculate during your consultation.
BMI and weight considerations
Some insurers impose body mass index (BMI) restrictions, typically requiring a BMI under 30. If you’re above this threshold, you may be advised to lose weight first, as insurers may argue that breast size could be reduced with general weight loss alone.
How to get insurance to cover breast reduction
To start the process, you must consult with a board-certified surgeon like Dr. Frank Lalezar. He’ll perform a physical exam, assess your symptoms, and help document your medical necessity. Our insurance team will assist in submitting the necessary paperwork, including:
- A letter of medical necessity
- Photos for documentation
- Medical records and treatment history
- Estimated tissue removal and Schnur Scale calculations
If your claim is denied, Dr. Lalezar’s team can also guide you through the appeals process.
Schedule Your Consultation
If you believe you may be a candidate for an insurance-covered breast reduction, now is the time to take the first step. Dr. Frank Lalezar is a board-certified plastic surgeon in New York City with extensive experience in breast reduction surgery and insurance-based care. Our team is happy to walk you through the entire process from consultation to claim submission and help you receive the care you deserve. Schedule your consultation today to explore your options.
