Breast Reduction Coverage

When breast reduction is a medical necessity

Breast reduction (reduction mammaplasty) is sometimes viewed as a purely cosmetic procedure, but for many patients, it is medically necessary care. Large, heavy breasts can contribute to chronic neck, back, and shoulder pain, skin rashes, posture problems, and activity limitations. When conservative treatments fail, surgery may be the most effective way to relieve symptoms. Our practice has a strong track record of helping eligible patients obtain insurance coverage for breast reduction when it meets the medical necessity standards.

Important: Every insurance company—and sometimes each plan—has its own criteria for coverage. This page explains common patterns, but your specific benefits will depend on your policy.

When Do Insurers Consider Breast Reduction “Medically Necessary”?

Although criteria vary by plan, many insurers look for some combination of the following factors:

Documented physical symptoms, such as:
- Chronic neck, back, or shoulder pain
- Shoulder grooving from bra straps
- Recurrent rashes, infections, or skin breakdown under the breasts
- Numbness, headaches, or limitations in activity

Duration of symptoms, often for many months or years
Failure of conservative treatments, such as:
- Physical therapy
- Chiropractic care
- Supportive garments
- Weight loss efforts (when appropriate)
- Medications or topical treatments for rashes

Clinical findings on examination, including significant breast hypertrophy and its impact on posture or musculoskeletal function
The estimated volume of breast tissue to be removed, often based on your height, weight, or body surface area

Insurers use this information to decide whether a reduction is addressing a medical problem rather than a purely cosmetic concern.

The Schnur Sliding Scale and Other Measurement Tools

One of the best-known tools used by many insurers is the Schnur Sliding Scale. This chart was developed to relate a patient’s body surface area to the minimum grams of tissue typically removed per breast when a reduction is performed for medical, rather than cosmetic, reasons (ASPS Recommended Insurance Coverage Criteria for Third-Party Payers | Reduction Mammaplasty).

We would like to highlight the following:

If the estimated grams of tissue per breast fall above specific percentile cutoffs for your body surface area, some insurers are more likely to consider the procedure medically necessary.
If the estimated amount is below those thresholds, some insurers may classify the surgery as cosmetic—even if symptoms are present.
The Schnur scale is not the only factor insurers consider; documentation of symptoms and a history of failed conservative treatment remains essential.

Our surgeons will estimate the amount of tissue to be removed and can explain how this aligns with commonly used scales. However, final coverage decisions always rest with your health plan.

How Richmond Plastic Surgeons Helps With Breast Reduction Coverage

Our team is well-versed in the documentation that insurers typically require. To support your case, we will:

Conduct a thorough consultation and physical exam, documenting symptoms, duration, and impact on daily life
Review your history of conservative treatments (physical therapy, chiropractic care, medications, specialty bras, etc.)
Take clinical photographs when required by your insurer
Calculate or estimate body surface area and projected tissue removal, and reference commonly used guidelines where appropriate
Submit a detailed letter of medical necessity and required forms to your insurance company before surgery, whenever preauthorization is needed
Assist with appeals if a medically necessary case is denied

We will always be honest with you about how strong your case appears based on your plan’s typical criteria, while remembering that each insurer makes its own final determinations.

What You Can Do to Strengthen a Potential Coverage Request

If you are considering breast reduction and hope to use insurance, you can:

Keep records of prior treatments:

Physical therapy or chiropractic notes
Primary care visits documenting pain and skin issues
Prescriptions or over-the-counter treatments tried

Note how symptoms affect your daily life, such as difficulty working, exercising, sleeping, or finding supportive clothing
Call your health plan and ask:
- “Does my plan ever cover breast reduction as medically necessary?”
- “What specific criteria and documentation are required?”
- “Is preauthorization required, and if so, what is the process?”

Please bring any written information from your insurer to your consultation so we can ensure our documentation aligns with their stated requirements.

We’re Here to Help You Navigate

Whether you are dealing with out-of-network questions, planning breast reconstruction after mastectomy, or exploring breast reduction for medical reasons, you don’t have to face insurance decisions alone. Our team at Richmond Plastic Surgeons is happy to review your situation and help you take the next step with confidence. Contact us today.