Is breast reduction covered by health insurance?

Insurance and having a Breast Reduction:  what you need to know

A Breast Reduction or Reduction mammoplasty is a surgical procedure that reduces the size of the breasts by removing breast tissue and repositioning the nipple.  Correcting the overly large or hanging breast can permanently relieve discomfort including neck, back, shoulder pain, poor posture, shoulder grooving, headaches and tingling down the arms.

How does insurance (BCBS) consider a Breast Reduction?

“Current literature (has) documented that reduction mammoplasty is associated with the relief of physical and psychosocial symptoms”. (BCBS guidelines for Breast Reduction)

So it is clear that a breast reduction results in relief of disability

What “codes” do you need to give to the insurance company?

(procedure codes):  CPT codes:  19813-50

(diagnosis codes): ICD-10 Codes:  N64.4, L30.4, M95.4, M54.6, M54.2, M25.511-519

How does insurance (BCBS) differentiate a “cosmetic” from a “medically necessary” breast reduction?

“A cometic procedure (is) performed primarily to improve the appearance of the breast…a medically necessary procedure is performed primarily to relieve documented clinical symptoms.  Emotional and psychosocial distress associated with body appearance does not constitute a medical rationale for reduction mammoplasty.”

Essentially, a breast reduction is cosmetic when the motivation is to improve appearance only and “medically necessary” when there are documented clinical symptoms

What benefits will insurance provide when Dr. Ditesheim does my surgery?

Dr. Ditesheim is not a “participating provider”.  This means that he does not have any contract with insurance companies.  This allows him to customize your breast reduction surgery to give you the best result, the size you want and with less scar.  You can use “out-of-network” benefits to receive reimbursement from your insurance.  This depends on your policy specifics, the process and documentation required and the specific insurance company “criteria” for what is considered “medically necessary”.  The information and literature referenced below can be helpful when insurance denies coverage.    We cannot “file” for you or negotiate with your insurance company.  It is your responsibility to know what documentation and process is required for reimbursement Before your procedure. 

Talk to you insurance company, find out your out-of-network benefits.

How do insurance companies determine the “required” amount of breast tissue to be removed? 

There is a sliding scale based on body surface area called the Schnur Sliding Scale.  It is derived from an article written over 30 years ago by

Paul Schnur, a well-respected plastic surgeon and published in the Annals of Plastic Surgery 1991 “Reduction Mammoplasty: Cosmetic or Reconstructive Procedure?”(1).  This study was initially not designed to predict the amount of tissue to be removed, but rather to provide a cutoff for the insurance companies to determine medical necessity.  Problems:   This study did not use a validated questionnaire that looked at how patients functioned after the surgery, nor did it take into account other parameters such as age, density of breast tissue or body mass index.  Despite its limitations, insurance companies are still relying on the Schnur scale to guide reimbursement of reduction mammoplasties 30 years later. 

Insurance companies are using a “sliding scale” to define “medically necessary” when multiple more contemporary studies have shown breast reduction surgery benefit is not tied to amount of breast tissue removed.

1. Is the insurance company criteria accurate and validated with current medical literature?

No. The Schnur scale has been studied and found to have low predictive value.  Today better models exist and have been published using a validated questionnaire (Breast-Q*).  These studies are prospective (looking at how women rated their disability before and after the surgery), focus on young women ( age under 25),  evaluate different models of health outcome to see if current criteria are still validated, and follow women for up to 21 years. All these studies asked the question “Does breast reduction surgery provide a functional ( relief of disability) improvement in quality of life, psychosocial functioning, self-esteem, bodily pain and breast-related symptoms?”  In each of these studies, there was strong evidence that breast reduction surgery has significant functional benefit and resection weight does not correlate with the degree of symptomatic relief after reduction mammoplasty.

More contemporary studies clearly document the functional benefit of having a breast reduction, independent of the amount of tissue removed.

2. Is the functional benefit of reduction mammaplasty dependent on amount of tissue removed?

“Redefining the Role of Resection Weight Prediction in Reduction Mammaplasty and Breaking the “One-Scale-Fits-All” Paradigm”(4).  328 pts were evaluated retrospectively after breast reduction surgery using the Breast-Q.   Different published models were evaluated and the Schnur model (used by insurance companies) was found to be of low predictive value.   More than one-third of patients, with reduction weights less than 500gm, who would not have qualified for reimbursement from third-party payers, had documented symptomatic relief postoperatively.

No, the relief of discomfort and disability is not dependent on the amount of tissue removed.

3.What is the Breast-Q and why is it important?

The Breast-Q is a validated condition-specific patient-reported outcome instrument.  This instrument is the most precise tool to measure the impact of a health condition and the success of surgical intervention from the patient’s perspective.  

“Outcomes of Breast Reduction Surgery Using the Breast-Q:  A Prospective Study and Comparison with Normative Data”(5).  132  Australian women were studied before and one year after a breast reduction using the Breast-Q.   Marked improvement in health-related quality of life was experienced by patients regardless of age, body mass index or minimum resection.  This is the largest prospective study to date using a validated questionnaire model.  This study “supports previous findings that there is no evidence or rationale to justify any policy that restricts funding for reduction mammaplasty based on arbitrary cutoffs for body mass index or a minimum weight of resection.”

The Breast-Q is a validated questionnaire.  In Australia, women were significantly helped with a breast reduction regardless of age, BMI or amount of resected breast tissue.

4.What is the evidence for long term functional benefit after breast reduction surgery in young women?

“Breast-Related Quality of Life in Young Reduction Mammaplasty Patients: A Long-term Follow-up Using the Breast-Q”(2).   This study followed 37 women with a median age of 20 years for a median follow-up of 21 years.  This was a retrospective study using the Breast-Q post-operatively.  Conclusion:  “Young reduction mammaplasty patients experience excellent breast-related quality of life decades after surgery”.  They found that age at time of surgery, amount of tissue removed and body mass index did not significantly change outcome.

The benefits of having a breast reduction were still present over 20 years later.

“Complications and Quality of Life following Reduction Mammaplasty in Adolescents and Young Women”(3).  512 young women were followed for up to 7 years to determine benefits of reduction mammoplasty.  They noted that 80% of women had been symptomatic since their teens, despite being told to either wait or not to have surgery for relief of symptoms. Once again, this study confirmed that reduction mammaplasty demonstrated “gains in physical well-being, bodily pain, psychosocial functioning, self-esteem and breast related symptoms.

Breast reduction surgery can have significant benefit especially in young women.

5.How do women with breast hypertrophy compare to “normal” women before and after surgery?

The study above showed that “breast hypertrophy represented a significant health impairment to women, with preoperative scores significantly lower in all areas of satisfaction and health-related quality of life.  At one year after the breast reduction procedure, scores increased significantly across all Breast-Q scales to levels at least equivalent to the norm.    This demonstrates long-term benefit and success of breast reduction surgery in bringing satisfaction and quality of life to levels of the general female population.

Breast reduction surgery can permanently remove the disability of large heavy breasts.

PRS: Plastic and Reconstructive Surgery Journal

References:

1. Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP. Reduction mammaplasty: Cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27:232-237.
2. Krucoff KB, Carlson AR, Shammas RL, Mundy LR, Lee HJ, Georgiade GS. Breast-related Quality of Life in Young Reduction Mammaplasty Patients:  A Long-Term Follow-up Using the Breast-Q .  Plastic and Reconstructive Surgery.  2019; 144:743e-750e.
3. Nuzzi LC, Firriolo JM, Pike CM, DiVasta AD, Labow BI. Complications and Quality of Life following Reduction Mammaplasty in Adolescents and Young Women. Plastic and Reconstructive Surgery. 2019; 144:572-581.
4. Boukovalas S, Padilla PL, Spratt H, Tran JP, Li RT, Boson AL, Howland N, Phillips LG. Redefining the Role of Resection Weight Prediction in Reduction Mammaplasty and Breaking the “One-Scale-Fite-All” Paradigm. Plastic and Reconstructive Surgery.  2019; 144:18e-27e.
5. Crittenden TA, Watson DI, Ratcliffe J, Griffin PA, Dean NR. Outcomes of Breast Reduction Surgery Using the Breast-Q: A Prospective Study and Comparison with Normative Data. Plastic and Reconstructive Surgery. 2019; 144:1034-1044.