Breast reduction surgery, or reduction mammaplasty, is a life changing procedure for women whose breasts are too large and heavy for their frames, whose breasts are uneven in size, and for those whose breasts sag or droop due to age or breastfeeding. In addition to improving self-esteem and improving physical activity, many women seek breast reduction surgery to get relief from neck, shoulder and back pain.

The Mayo Clinic advises women considering breast reduction surgery to discuss all facets of the surgery with several board certified plastic surgeons. The surgeons will assess their candidacy for surgery and determine whether reduction mammaplasty is appropriate for them. Women should ask questions regarding the procedure and post-operative care to establish appropriate expectations.

In fact, obtaining this information prior to the appointment will allow a patient to form more specific questions about the breast reduction. A frank discussion with the surgeon should alleviate fears and provide the patient with a realistic expectation of the outcome. She and her physician will decide together the most beneficial amount of reduction and the best time for her to have it performed.

The American Society for Aesthetic Plastic Surgery warns women of child bearing age that mammaplasty may hinder their ability to breast feed. They further warn that pregnancy, childbirth, and breast feeding, if the woman is able to do so after breast reduction surgery, could change the shape of her breasts. They stress discussing future pregnancies with the performing physician.

Reduction mammaplasty is performed under general anesthesia in a surgical facility and may require an overnight stay. If the patient is released the day of the surgery, she must have a ride home and should have a caregiver for at least the first night she is home. Driving is usually prohibited for six weeks.

Recognizing the disabling effects of larger breasts, many insurance policies cover at least a portion of the cost. A diagnosis of female breast hypertrophy with its attendant consequences and disabilities or reconstructive breast surgery which results in breast reduction is usually compensable. Breast reduction for strictly cosmetic reasons is seldom covered.

There are many variables in surgical technique including how the incisions are placed and the maximum amount of reduction advised, so a prospective patient might consult more than one plastic surgeon before making her final decision. Each consultation will be educational and help the woman decide whether or not this procedure will benefit her.

Benefits of reduction mammaplasty range from relief of physical pain formerly associated with the strain and weight of the breasts to finally getting a full night’s rest. The ability to buy lacy or pretty bras for the first time in years delights most patients. Shopping for bras and tops in a regular store instead of by catalog or at larger sized stores makes shopping fun again for most.

A world of activities opens up to women after breast reduction surgery. Some play tennis or racquetball for the first time. Others join a bowling league or gym, no longer embarrassed or hampered by their super-sized breasts. For all, the absence of those extra pounds of breast flesh seems to be a huge relief.

Medically necessary services are generally services that are provided to enhance one’s quality of life, physical or emotional functioning, and promote adequate development throughout the lifespan. These services should be provided only after individualized assessment of each person’s needs by a physician, or otherwise qualified professional, and the least intensive and intrusive services necessary to achieve the desired outcome should be the services that are provided.

With specific regards to plastic surgery, any procedure conducted with the primary intention of improving appearance is generally not considered medically necessary, unless it can be documented that a specific disfigurement is directly impacting the quality of one’s life. Plastic surgery procedures that are conducted to improve functioning that happen to result in improved appearance, however, can be considered medically necessary. For example, if excess scar tissue is impairing movement or causing pain, the removal of this scar tissue can be considered medically necessary to improve functioning, yet will most likely also result in an improvement in appearance. Other surgical procedures that are generally considered medically necessary are the removal of tumors, dermabrasion to improve deep scaring, rhinoplasty to improve a sinus condition, and reconstructive surgery. Breast reductions that are conducted to alleviate back and neck pain should also be covered as medically necessary under most health plans that cover reconstructive surgery.

To ensure that a plastic surgery procedure will be covered as medically necessary, there are several precautionary measures that the consumer can take. First, it is important for the consumer to identify whether his or her insurance coverage falls under state or federal regulations regarding reconstructive surgery. This can be done with a simple phone call to the insurance provider. Once this is done, the consumer can research the legal requirements regarding plastic surgery for their insurance provider. Generally state laws require more coverage than federal laws do, although current legislation being passed through the House and the Senate is intended to legally require all insurance companies to cover reconstructive surgery, and to create a more comprehensive and clear definition of the difference between reconstructive surgery and cosmetic surgery.

To find the legal requirements regarding reconstructive surgery in each state, click here. This website generally discusses breast reconstructive surgery, but the laws outlined here should apply to all types of reconstructive surgery. Once the consumer understands what is covered in his or her insurance policy, then he or she can go to a practitioner who specializes in the specific surgery or procedure. It is important to ensure that the medical professionals evaluating the necessity of the procedure take careful documentation, including pictures when appropriate, to send into the health insurance company for approval. Once all of the necessary documents and medical referral for surgery are sent in to the insurance company, the insurance company will decide whether to approve or deny coverage. If coverage is denied, then the consumer can request a re-evaluation of the case and use documentation of state and federal law along with physician reports to support their request.  If the procedure indeed falls within the terms of coverage and the state and federal laws regarding coverage, then the recommended surgery should be covered.