Navigate Insurance Approval for Breast Reduction Surgery: A Comprehensive Guide

Introduction

Many women experience discomfort and health issues due to disproportionately large breasts. Large breasts are medically known as macromastia or gigantomastia.

Large breasts can significantly interfere with daily activities and overall quality of life in many ways. One solution for the treatment of large breasts can be breast reduction surgery. Breast reduction surgery is medically known as reduction mammoplasty. This surgery is often sought for both physical and emotional relief.

This article explores how to maximize your attempt to obtain medical insurance coverage for breast reduction. However, insurance approval for breast reduction surgery can be a complex and often frustrating process. This guide aims to demystify the process and provide practical tips for securing medical insurance approval.

First, let's explore some of the hardships women may have with large breasts.

Physical Discomfort and Pain:

1. Back, Neck, and Shoulder Pain: The weight of large breasts can strain the neck and upper and middle back. Because of their weight, large breasts can also exert chronic pressure on the back, leading to chronic pain in the back, neck, and shoulders. Over time, this chronic pressure can lead to premature curvature of the spine and other permanent changes in the bone structure of the spine.
2. Poor Posture: If a patient's breasts are too heavy and their back muscles cannot support the weight, this situation can lead to poor posture. Unfortunately, poor posture can exacerbate back and neck issues.
3. Bra Strap Grooving: The pressure from the bra straps supporting heavy breasts can cause painful shoulder indentations and grooves. This pressure can lead to skin irritation and infections as the bra strap digs into the shoulders.

Exercise and Physical Activity Limitations:

1. Discomfort During Exercise: Large breasts can make physical activities, including running, jumping, or aerobic exercises, uncomfortable or painful due to excessive breast movement.
2. Avoidance of Physical Activity: Individuals may avoid exercise or physical activities due to discomfort and embarrassment—this avoidance can impact overall health and fitness. Therefore, because of difficulties in the ability to exercise, macromastia can increase a patient's chance of becoming obese.

Skin Issues:

1. Under-Breast Rashes and Infections: The skin under large breasts can often trap sweat and accumulate moisture. Also, because of large breasts, the skin under the breasts rarely is exposed to air.
   1. This combination of moisture and no air can lead to bacterial and fungal infections that are difficult to treat.
   2. Also, due to large breasts and poorly fitting bras, the skin under large breasts is prone to rubbing and friction.
   3. This constant friction can cause skin irritation under the breasts and can lead to further rashes and infections.
2. Stretch Marks: The skin covering large breasts may stretch significantly. This skin stretch can lead to stretch marks.

Clothing and Bra Fitting Issues:

1. Difficulty Finding Properly Fitting Bras and Clothes: It can be challenging to find bras that provide adequate support and clothing that fits comfortably and flatteringly.
2. Limited Fashion Choices: Large breasts can limit clothing options and affect personal style and expression.

Sleep Disturbances:

Discomfort While Sleeping: Finding a comfortable position can be difficult, leading to sleep disturbances.

Psychological and Emotional Impact:

1. Self-Consciousness and Body Image Issues: Large breasts can lead to feelings of self-consciousness, negatively impacting body image and self-esteem.
2. Unwanted Attention: Individuals may also experience unwanted attention or comments, leading to discomfort and psychological stress.

Non-Participation in Social Activities:

Avoidance of Social Situations: Due to physical discomfort or self-consciousness, individuals with large breasts might avoid social activities, impacting social life and relationships.

These challenges emphasize the importance of addressing macromastia not just as a cosmetic issue but as a medical concern that can profoundly affect one's lifestyle and well-being. For those experiencing significant interference in daily living due to large breasts, consulting with a plastic surgeon for appropriate management and treatment options is advisable.

Now that we know what many patients with large breasts experience, let's look at what can be done about it.

Understanding the Basics of Medical Insurance and Elective Surgeries

Before delving into the specifics of breast reduction surgery, it's essential to understand how medical insurance views elective breast reduction surgeries. Most medical insurance companies categorize breast reduction as both a cosmetic and a medically necessary procedure, depending on individual circumstances. It's vital to prove the medical necessity of breast reduction surgery for insurance coverage.

Objective tools to determine if you qualify for medical insurance coverage for your breast reduction

There are two objective tools plastic surgeons and insurance companies use to determine if you qualify for a breast reduction: the Schnur Sliding Scale and Breast Ptosis Guide.

The Schnur Sliding Scale: A Key Tool in Your Breast Reduction Approval Process

The Schnur Sliding Scale is a tool used in plastic surgery and the medical insurance field. This scale is used for breast reduction surgery to help determine whether a breast reduction is medically necessary for a patient. This scale was developed by a plastic surgeon (you guessed it…Dr. Paul Schnur) and is often used by insurance companies as part of their criteria for approving breast reduction surgery coverage.

Here's how the Schnur Sliding Scale works:

1. Body Surface Area (BSA) Calculation: The first step is calculating the patient's Body Surface Area (BSA). BSA is a measure of the total surface area of the human body. BSA is used in the Schnur Scale to correlate the amount of breast tissue needing removal to qualify for approval.
2. Amount of Tissue to be Removed: The plastic surgeon estimates the amount of breast tissue that needs to be removed from each breast to achieve a functional and aesthetic result. This estimation is based on physical examination and experience.
3. Percentage Calculation: The estimated weight of the breast tissue to be removed is then expressed as a percentage of the patient's BSA. This percentage is used to determine the necessity of the surgery.
4. Interpreting the Scale: The Schnur Scale is a chart that correlates the percentage of tissue to be removed with the likelihood of the surgery being medically necessary. If the percentage falls within or above a certain range on the scale, the breast reduction surgery is more likely to be deemed medically necessary. For instance, removing a higher percentage of breast tissue in relation to a smaller BSA generally strengthens the case for medical necessity.

The Schnur Scale (1)

Example #1: A 5" 10" 140-pound female would have a body surface area of 1.79 m2. Per the Schnur Scale, 441 grams of breast tissue would need to be removed from each breast to qualify for medical insurance authorization.

Example #2: A 5'10" female who weighed 200-pounds would have a body surface area of 2.14 m2. Per the Schnur Scale, 819 grams of breast tissue would need to be removed from each breast to qualify for medical insurance authorization.

Another method to objectively describe the breast is by classifying the breast in accordance with the position of the nipple-areolar complex. The position of the nipple-areolar complex in relation to the rest of the breast can change due to aging, gravity, weight fluctuations, pregnancy, and breastfeeding. The classification of breast ptosis is based on the position of the nipple relative to the inframammary fold and the level of breast tissue sagging. The medical word for sagging is ptosis. Therefore, breast ptosis is breast sagging. Here are the different types of breast ptosis:

1. Mild (Grade I) Breast Ptosis: In mild ptosis, the nipple is at the inframammary fold level but remains above most of the lower breast tissue. This grade represents a minor degree of sagging.
2. Moderate (Grade II) Breast Ptosis: In this case, the nipple is below the inframammary fold but higher than most breast tissue. This situation indicates a more noticeable degree of sagging than in mild ptosis.
3. Advanced (Grade III) Breast Ptosis: The nipple is significantly below the inframammary fold and points downwards. The majority of the breast tissue has also sagged below the fold. This position is a more severe level of sagging.

The purpose of the Schnur Sliding Scale and Breast Ptosis Gradation is to provide an objective measure to differentiate between breast reduction surgeries that are primarily cosmetic and those that are medically necessary. However, it's important to note that the use of the Schnur Scale can vary among different insurance companies and is just one fact among many that they consider when evaluating claims for breast reduction surgery. (2)

Documenting Symptoms: Building a Strong Case

Insurance companies require comprehensive documentation of physical symptoms caused by large breasts. Here are some common symptoms that strengthen your case:

1. Shoulder Groove Pain: Documenting this condition with photos and medical records from a physical therapist, back surgeon, or chiropractor can be compelling evidence.
2. Shoulder Pain and Back Pain: Chronic pain in these areas, especially if it can be linked directly to breast size, is a significant factor. Medical records showing ongoing treatment for these issues, including physical therapy or chiropractic care, are crucial.
3. Headaches: While not as directly linked as other symptoms, chronic headaches exacerbated by large breasts (due to posture or tension) can also be a supporting argument. Medical records from a Neurologist or headache specialist would help here.

Consulting with Healthcare Professionals

Consultations with your primary care physician, plastic surgeon, physical therapist, or chiropractor are essential. These professionals can provide medical opinions and documentation supporting the surgery's necessity.

Gathering Documentation and Preparing Your Case: Filing a Claim and Handling Denials

Prepare a comprehensive file including your medical history, documented symptoms, treatments tried, medical quality photographs, and professional opinions. Letters from healthcare providers that detail how breast reduction will alleviate your symptoms are particularly persuasive.

Filing a claim requires submitting all collected documentation to your insurance provider. You and your plastic surgeons need to be meticulous and follow all guidelines provided by your insurance.

Here are the requirements for breast reduction for Blue Cross/ Blue Shield.

Here are the requirements for breast reduction for United Health Care.

Here are the requirements for breast reduction for Aetna.

If your claim is denied, keep hope. You have the right to appeal. An appeal process involves reviewing your case, often with additional information or clarification.

This is a 43-year old 5’7” White female who had EE breasts. She had neck pain, upper back pain, middle back pain, and rashes under her breasts. She avoided social situations and exercising in public. She underwent a four-hour breast reduction surgery. She had an anchor breast reduction incision with removal of about 850 grams of breast tissue on each side. She is very happy she underwent her breast reduction with Dr. Katzen.

Tips for a Successful Breast Reduction Insurance Claim

1) Start documenting your symptoms and treatment attempts as early as possible.

2) Be consistent with your medical appointments and treatments.

3) Record how your breast size affects your daily life physically and emotionally.

4) Chose a plastic surgeon who is willing to work with insurance companies

5) Obtain a detailed letter from your plastic surgeon

1) using the Schnur Scale

2) documenting pain resulting in work loss and interference with activities of daily living

3) documenting pain that was not relieved with a six-week course of non-steroidal anti-inflammatory agents/muscle relaxants.

4) linking your symptoms to the need for surgery

5) including medical quality photographs

Conclusion

Securing insurance coverage for breast reduction requires patience, documentation, and understanding of the criteria set by your medical insurance company. Following these guidelines and preparing a thorough case advocating for your health increases your chances of a successful claim. Remember, breast reduction surgery is not just a cosmetic procedure. For many patients struggling with large breasts, breast reduction surgery is a path to a pain-free, healthier life.

1) Quick Calculation of Breast Resection Mass Using the Schnur Scale. Lucas A Dvoracek 1, Jeffrey A Gusenoff, J Peter Rubin, Ernest K Manders, Ann Plast Surg. 2019 Mar;82(3):316-319. doi: 10.1097/SAP.0000000000001643.

2) Breast Resection Weight Prediction and Insurance Reimbursement in Reduction Mammaplasty: Which Scale Is Reliable? Yan, Maria M.D. et al. Plastic and Reconstructive Surgery 150(4):p 723e-730e, October 2022.