Do I Qualify for a Breast Reduction?

Do I Qualify for a Breast Reduction?

When a woman has larger, full breasts, their weight can create additional stress on the body and cause aches and pains. Some women experience back, neck, and shoulder pain due to the larger size of their breasts.

It can also be challenging for a person with larger breasts to find bras that fit, and tops and sweaters can fit off-kilter. Running and playing sports become more challenging and increase the discomfort felt. A breast reduction procedure is not always done just for weight loss but because large breasts can present challenges for women. 

Sometimes, a woman whose entire life is affected by her larger breast size will consider breast reduction surgery to lessen the mass of the breast. Insurance will pay for breast reduction surgery in some instances, depending on the circumstances. Not every woman with large breasts is an ideal candidate.

It is essential to consult with a board-certified plastic surgeon to determine if you are a good candidate for breast reduction. There are various factors taken into consideration for people seeking a breast reduction procedure. The professional staff at Wave Plastic Surgery can help you determine if a breast reduction is right for you. 

How To Qualify For Breast Reduction

No set breast size qualifies or disqualifies a person for breast surgery or disqualifies their health insurance from paying for the surgery. For insurance to cover breast reduction, it must be medically necessary and not for cosmetic reasons alone. 

However, women come in all shapes and sizes. For example, a woman who stands 5’11” tall would have much heavier breasts than one who is 5’3″ tall when they wear the same cup size.

Schnur Sliding Scale

Over the years, insurance companies have come up with a way to determine when a person’s breasts are large enough to qualify for coverage. In the United States, most health insurance companies use the Schnur Sliding Scale to determine if breast reduction is medically necessary. 

The Schnur Sliding Scale looks at the ratio between the weight of breast tissue that needs to be removed during the surgery to the total body surface area of the person. While the Schnur Sliding Scale is important in the decision of an insurance company, they do look at other factors. 

For a woman to easily qualify using the Schnur Sliding Scale, she needs to be above the 22nd percentile. This is usually the cut-off point for the procedure being medically necessary, but other factors can play a part.

If a woman is in or below the fifth percentile, it’s almost always considered a cosmetic procedure. For women between the fifth and 22nd percentile, the insurance company can consider other factors before making a final decision. 

qualifying for breast reduction

What Factor Does Age Play in Qualifying for Breast Reduction Surgery? 

A surgeon will perform breast reduction surgery on almost any aged woman. However, these surgeries are performed on women who have completed puberty and whose breasts have reached their full size.

Most insurance companies won’t approve breast reduction for young ladies under the age of 15, and some companies have an age requirement of at least 16 years old. Some doctors may use the Tanner Stages, or Sexual Maturity Rating (SMR), to determine if the person has reached their growth potential. 

The surgeon, patient, and insurance company don’t want the person to need another breast reduction in the future because they weren’t done growing. Although the insurance companies assign an age, the doctor will examine the young woman to determine if she’s done growing. 

If the doctor feels like the person isn’t done growing breast tissue, they may postpone the idea of surgery for a few months or a couple of years. This postponement can be frustrating, but it’s what’s best for the patient and their overall well-being. 

For older women, there isn’t a specific age at which they’re no longer candidates for breast reduction. It’s important to consider the person’s overall health and determine if the person is healthy enough to undergo surgery. 

What Other Factors to Qualify for Breast Reduction?

To qualify for insurance to cover breast reduction surgery, a person must meet some other qualifications. There are also additional factors for a person considering breast reduction to weigh before making a decision. 

Here are some factors that need to be considered:

  • Health issues created by larger breasts and documented by a doctor, such as:
    • Pain in the neck, shoulders, and back
    • Skin rashes and infections
    • Permanent indentations in the shoulders from bra straps
    • Nerve compression can be pinpointed to the weight of the breasts
  • The person has tried alternative treatments to minimize the health issues
  • The detailed medical history of the patient
  • In some cases, larger breasts can affect the person’s ability to play sports or take part in everyday activities.
  • History of breast cancer in the family
  • Current and past use of tobacco
  • If a person needs to or plans to lose a significant amount of weight, it’s best to do this before breast reduction surgery.
  • The amount of breast tissue that needs to be removed
  • The person’s overall quality of life

Many of these qualifications need to be met to get an insurance company to cover the procedure. In the case of medical issues, the patient needs a letter from their doctor who documents a history of medical issues connected with the size of the breasts.

For an insurance company to cover breast reduction surgery, they usually expect over 12 ounces of breast tissue to be removed. A lower reduction of breast material is typically considered a breast lift and won’t be covered. However, these are all guidelines and not hard and fast numbers. 

things to know about breast reduction surgery

Learn More About Breast Reduction With Wave Plastic Surgery

Even when a person qualifies for breast reduction surgery, they need to carefully choose the right course for themselves. They need to start by sitting down with a doctor and their team to discuss the qualifications, their situation, the details of the surgery, and the expected outcome. 

At Wave Plastic Surgery, we take pride in helping women alleviate their pain and improve their quality of life with breast reduction. Our team members provide compassionate care at every stage of a patient’s journey. 

Contact us today to learn more about breast reduction surgery!

Ben Lee

Ben Lee

Dr. Lee received his bachelor’s degree in molecular and cellular biology with highest honors from the University of Colorado in Boulder. He went on to earn his M.D. with highest honors from the University of Colorado School of Medicine in Denver, followed by his MBA from the University of Colorado Denver. He completed his surgical internship at the University of California at San Francisco. Going on to train in otolaryngology/head & neck surgery at Duke University Medical Center, working closely with the plastic surgeons during his head and neck residency inspired him to continue training in plastic and reconstructive surgery. After this specialized training, Dr. Lee went on to become Board Certified in Plastic Surgery.

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