What this is, in plain language
Surgery to remove excess breast tissue, skin, and fat to reduce breast size and relieve related symptoms.
Why a clinician orders it
Symptoms like neck/back/shoulder pain, posture changes, skin irritation under the breasts, or grooving from bra straps that have not improved with conservative care.
Medical necessity — what insurers usually look at
Insurers usually distinguish between cosmetic and medically necessary reduction. Common requirements include documented symptoms, conservative treatment tried, and an estimated grams of tissue to be removed based on body size (often using the Schnur scale).
Documentation to ask about
- ✓Documentation of symptoms over time
- ✓Conservative treatment (PT, supportive bras, weight management)
- ✓Photographs as required by the plan
- ✓Estimated grams to be removed
Questions for your provider
- ?Does my insurer use the Schnur scale or another formula?
- ?What is the appeal process if the request is denied as cosmetic?
Terms you'll see
The insurer is reviewing whether the service is clinically appropriate for your situation.
The insurer may view the service as appearance-related rather than treating a medical condition.
Some services may need plan approval before they are performed.
Lower-risk care that insurers may want documented before a bigger procedure.