When Is Breast Reduction Necessary?

However, in some cases, the surgery is medically necessary. Some new guidelines may help surgeons and health insurers make the right decision.

For example, a doctor prescribes a breast reduction for a young woman who is five feet tall, weighs 135 pounds, and is 32 years old. A plastic surgeon recommends removing 500 g of breast tissue from each breast. Is this breast reduction surgery considered medically necessary and is it likely to be covered by health insurance?

When breast reduction or augmentation is performed on an abnormal structure of the body caused by disease, infection, congenital deformity, trauma or tumors, the reconstructive surgery is considered medically necessary and is generally done to improve the body's function, according to the American Medical Association (AMA, Chicago, IL, USA).

Physical reasons such as shoulder, back, and neck pain; grooving caused by brassiere straps and eczema; and the wearing of a normal-sized brassiere with a large cup size are some symptoms that surgery is medically necessary. Taking nonsteroidal anti-inflammatory drugs (NSAIDs), years of chiropractic treatment without alleviation of symptoms, and symptoms and complaints typical for a diagnosis of macromastia (excessively large breasts) all point to a medical need for surgery, according to Dr. Skip Freedman, medical director at ALLMED Healthcare Management (Portland, OR, USA), a U.S. independent review organization (IRO) that offers a panel of experts to help payers ensure patient treatments are medically necessary.

Patients with congenital breast deformity or those who have experienced breast trauma, infection, tumors, or disease may qualify for breast augmentation or reduction. These include patients with Poland's disease or cancer, breast dropping caused by dramatic weight loss due to gastric surgery, significant breast asymmetry, or those who have had a mastectomy.