Breast Reduction Insurance Newport Beach

Breast Reduction Insurance Criteria

Breast reduction involves the removal of glandular tissue, fat, and skin from the breasts.  Most insurance companies consider approval for coverage of breast reduction on an individual, case-by-case basis, when needed to alleviate or correct medical problems caused by excessive breast tissue. Women presenting with various forms of breast overgrowth (for example, macromastia or gigantomastia) accompanied by persistent clinical signs and symptoms that adversely affect health are the principal candidates for breast reduction approval. 

Typically insurance companies consider breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete.  Depending on your policy most or all of the following breast reduction insurance criteria must be met:

1. Persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:

• Pain in upper back
• Pain in neck
• Pain in shoulders
• Headaches
• Painful kyphosis (back bone disorder) documented by X-rays
• Pain / discomfort / ulceration from bra straps cutting into shoulders;

1. Photographic documentation that confirms the overly large breasts
2. Evaluation by a physician who has determined that all of the following criteria are met:

• ·         There is a reasonable likelihood that the  symptoms are primarily due to macromastia; and
• ·         Reduction mammoplasty is likely to result in improvement of the chronic pain; and
• ·         The surgeon estimates that at least 350 grams or more of breast tissue will be removed from each breast.
• Persistent pain, as documented by the physician, despite a 3-month trial of therapeutic measures such as:
  • Supportive devices (e.g., proper bra support, wide bra straps)
  • Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
  • Physical therapy / exercises / posturing maneuvers

Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the inframammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty by most insurance companies. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g. good skin hygiene, adequate nutrition) for a period of six months or longer, but also must satisfy the criteria stated above.