Will Insurance Pay for My Breast Reduction?

Will Insurance Pay for My Breast Reduction?
Insurance companies base whether they will pay for a breast reduction (reduction mammoplasty) or not based on your current breast size, body size and shape, body weight, other contributing factors and, most importantly, the amount of breast tissue planned for removal.
Breast size
In a previous post I explained how the band size and cup size of the breasts are related to one another. In short, the band size is the circumference of the chest, and for every inch that the circumference at the nipples is greater than that of the chest, you get one larger cup size.  So, if you measure a band size of 34 inches and measure 37 inches at the nipples, you need a size 34C bra.Body size and shape
Body surface area is a measurement that relates your height to your weight.The normogram that shows this (developed in 1916!) is shown in the following link: http://depts.washington.edu/druginfo/Formulary/BSA.pdf
Body surface area is in turn related to the amount of breast tissue each patient has and the amount that must be removed for insurance companies to pay for breast reduction surgery. For example,  a 5’3” patient weighing 170lbs has a BSA of 1.79 m squared.Body weight
Body weight is also used in some cases to classify patients as being suitable for breast reduction or not. The idea the insurance companies have here is that they want to exclude patients who are “overweight” and who could potentially achieve a breast reduction through diet! there are obviously few women who fall into that group.

Patients are classified into three weight groups based on their body frame and height. (Metropolitan Insurance Company, 1983) If you are 5’2” and small-framed, your ideal weight is between 108 and 121 lbs. For the same height but with a medium or large frame, your ideal weight is between 118 and 132 lbs and 128 and 143 lbs respectively.

For an insurance company to consider paying for your breast reduction you must weigh no more than 30% over the midpoint of the large-frame weight for your height! This is exactly why you need to see a plastic surgeon who can calculate all these things for you.

Contributing factors
Factors such as skin infections and irritations and pain in the neck, back and shoulders play a role in determining the suitability of a patient for surgery.

Amount of breast tissue planned for removal
For each body surface area, an amount of breast tissue greater than 22% of the cut-off weight must be removed for insurance eligibility.

Look at the Schnur sliding scale chart below:

This scale establishes a relationship between body surface area and the amount of breast tissue that must be removed. If the amount to be removed is less than 22%, the surgery is deemed cosmetic in nature, and insurance will not pay.

In the example above, a patient with a body surface area of 1.79 meters squared, the patient will need to have 441 grams of breast tissue removed from each breast to fall within the guidelines for payment by an insurance company (assuming your policy covers breast reduction—many do not!).

Once all of the above measurements and calculations have been performed, your cosmetic plastic surgeon will take photos and write a letter requesting authorization of the surgery. It can take six weeks for the answer to come back, and what the answer will be has, in my experience, no rhyme or reason. There are obviously other factors that they consider in making their decision, but at least we will have done our share!

Need more information on breast surgery? Find it here: https://tavmd.com/breast_surgery.html