Executive summary — the 60-second answer

Insurance will sometimes pay for breast reduction when it is considered medically necessary (to relieve physical symptoms such as chronic back, neck or shoulder pain, recurrent skin infections under the breast, or neurologic symptoms). Requirements differ by carrier — many plans require documentation of symptoms, a trial of conservative therapy, photos, and a surgeon’s letter estimating tissue to be removed (resection weight or Schnur calculation). If an insurer denies coverage, you can (and should) appeal — internal appeal first, then external review if necessary.

1. The medical case for reduction mammaplasty: evidence & outcomes

Reduction mammaplasty (breast reduction) is supported by clinical studies showing consistent improvement in pain, physical function and quality of life for women with symptomatic macromastia. Systematic reviews and BREAST-Q outcome studies report high patient satisfaction and measurable benefit in pain reduction and physical functioning after surgery.

Takeaway: High-quality clinical literature supports surgery for symptomatic breast hypertrophy — this research is frequently cited in appeals and medical necessity letters. (See References below.)

2. How insurers decide — common medical necessity criteria (what you’ll run into)

There is no single national standard. Insurers typically review these elements:

• Documented symptoms — chronic upper back/neck/shoulder pain, bra strap grooving, intertrigo (rash beneath the breast), activity limitation, or neurologic complaints.
• Evidence conservative therapy was tried and failed — supportive bras, physical therapy, topical treatments, analgesics, weight loss attempts (timeframes vary between carriers).
• Objective measures — preoperative estimate of tissue to be removed (grams per breast), body surface area (Schnur Sliding Scale is commonly used by payers), photography of clinical findings, and sometimes documentation of mammography within specified timeframes.
• Surgeon/PCP documentation — clear letters from referring physician and the operating plastic surgeon explaining medical necessity and expected symptom relief.
• Plan language limits — some plans exclude breast reduction unless exceptions are met (check your Evidence of Coverage and member handbook).

Insurer policies vary: some require a multi-month conservative therapy trial (commonly 6–12 weeks, often 3 months), others may require resection weights or use the Schnur scale. The American Society of Plastic Surgeons (ASPS) recommends symptom-based decisions and warns against using rigid resection-weight cutoffs alone. See References.

3. Step-by-step playbook (what to do, day-by-day)

This section is the practical workflow your PCP, plastic surgeon and you should follow to maximize approval chances.

Step 0 — Do your homework (day 0)

1. Find your plan name, group number, and Evidence of Coverage (EOC) — usually available in your insurer’s member portal or your HR/benefits package.
2. Call Member Services and ask: “Does my plan cover reduction mammaplasty for symptomatic breast hypertrophy? Is prior authorization required? Are there minimum resection or BMI requirements?” Record the name, date, and what you were told.

Step 1 — See your primary care provider (days 1–14)

1. Document the problem in detail: exactly when pain started, how often it occurs, how it limits work/exercise/daily living, and what treatments were tried.
2. Ask PCP to document prior conservative treatments and refer you to physical therapy, dermatology (for intertrigo), or pain management as appropriate — conservative trials strengthen the case.

Step 2 — Conservative therapy (weeks 0–12, as insurer requires)

Typical conservative measures insurers expect to see documented include:

• Fitted, supportive bra (professional bra fitting if possible)
• Trial of physical therapy or posture/strengthening exercises (document sessions and response)
• NSAIDs or other prescribed analgesics (document prescriptions and effectiveness)
• Topical antifungal/dermatologic care for skin irritation (photo documentation)
• Weight-management counseling where relevant (some carriers require documented attempts if BMI is high)

Note: Required trial length varies by insurer — many require at least 6 weeks to 3 months of documented conservative therapy before approving surgery. Check the policy and document everything. If you’ve already tried these for months, obtain dated records to submit.

Step 3 — Consult a board-certified plastic surgeon (weeks 2–8)

1. Choose a surgeon with experience in insurance prior authorizations and a record of successful submissions.
2. During the consult have the surgeon: measure breasts, estimate resection weight per breast (grams), take professional preoperative photos (front, oblique, side — include rulers), document bra strap grooving, intertrigo, and other objective findings.
3. Ask the surgeon’s office to prepare a complete preauthorization packet: surgeon’s letter of medical necessity, operative plan (including estimated resection weight and CPT codes), copies of PCP and PT notes, photos, and relevant labs or imaging (mammogram if required).

Step 4 — Preauthorization: what the insurer will usually want

• Surgeon’s letter of medical necessity stating symptoms, duration, conservative therapy tried, and expected improvement.
• PCP and conservative therapy notes (PT visits, supportive bra receipts, medications, dermatology visits).
• Preoperative photographs showing clinical signs (rib groove, rash, posture changes).
• Estimate of tissue to be removed (grams per breast) and calculation using an insurer-preferred tool (Schnur sliding scale or other).
• Information that the patient’s breast growth is stable and any pregnancy/breastfeeding timing requirements are met.

Common codes: CPT 19318 (reduction mammoplasty) — include this in the precertification request and surgeon’s paperwork.

Step 5 — If approved: scheduling & financials

Confirm the approval letter, verify the exact CPT codes approved, ask about in-network vs out-of-network benefits, and confirm patient cost-sharing (deductible, copay, coinsurance). If the insurer approves only part of the request (e.g., lower resection weight), discuss options with your surgeon.

Step 6 — If denied: appeals & escalation

1. Request the denial letter in writing and note the denial reason and appeal deadlines.
2. File an internal appeal promptly. Have the surgeon prepare a detailed appeals letter citing clinical evidence, trial data, photos, and literature supporting benefit. Sample templates below.
3. If internal appeal fails, request an external independent review (state or federal external review processes exist for most plans). Follow HealthCare.gov/CMS guidance for external review submission.
4. If your plan is employer-sponsored and self-funded (ERISA), legal remedies differ — consider contacting a patient advocate or an attorney experienced in ERISA benefits if external review is exhausted.

4. Templates — copy/paste & use these

Sample: Surgeon Letter of Medical Necessity (brief)

[Surgeon letterhead]
Date: __________________

Re: [Patient name, DOB, Member ID]

To: [Insurer prior authorization department]

I am writing to request authorization for reduction mammoplasty (CPT 19318) for my patient, [name]. The patient presents with symptomatic macromastia including chronic upper back/neck/shoulder pain (since [date]), bra strap grooving, and recurrent intertrigo beneath the breast. Conservative measures attempted and documented in the chart include supportive fitting bra, 12 sessions of supervised physical therapy (dates), NSAID therapy, and dermatology care for recurrent intertrigo (dates). Symptoms have failed to improve and significantly limit activities of daily living and work.

Estimated tissue removal: [X] grams per breast (estimated using clinical exam and BSA). Photographs and relevant medical records are enclosed. In my professional opinion, reduction mammoplasty is medically necessary and is expected to significantly relieve the patient's symptoms and improve function.

Sincerely,
[Surgeon's name, MD, ABPS #, contact info]
      

Sample: Patient Appeal Letter (short)

[Patient name]
[Address]
[Member ID]
[Date]

To: [Insurer appeals]
Re: Denial of coverage for reduction mammoplasty

I am appealing the denial of coverage for my breast reduction surgery. I suffer from chronic upper back, neck, and shoulder pain since [date], bra strap grooving, and recurrent rashes under my breasts. I have tried supportive bras, physical therapy, and medications (see attached records) with little or no lasting improvement. My surgeon, Dr. [name], has documented that removal of approximately [X] grams per breast is medically necessary to relieve these symptoms. Please reconsider this denial in light of the enclosed medical records, surgeon's letter, and clinical evidence.

Sincerely,
[Patient signature]
      

5. What insurers commonly require (quick comparison)

These are examples — always check your plan's Evidence of Coverage and medical policy. Many payers publish detailed reduction mammaplasty criteria online (see References).

6. Common denial reasons — and how to answer them

1. “Not medically necessary” — respond with a surgeon’s letter, conservative therapy records, and peer-reviewed evidence showing improved QoL after surgery.
2. Insufficient documentation of conservative therapy — submit dated PT notes, prescriptions, bra fitting receipts, and PCP notes.
3. Doesn’t meet resection weight/Schnur — submit surgeon’s BSA calculation, planned grams, and literature showing benefit independent of resection weight.
4. BMI too high or recent weight change — provide records showing stable weight, nutrition counseling, or physician note explaining that high BMI does not negate benefit.

7. Alternatives if insurance refuses

• Negotiate a self-pay discount with the surgeon/hospital (many practices offer cash pricing).
• Medical financing (CareCredit and similar health/medical credit lines).
• Hospital charity care or sliding-scale programs (ask hospital financial counseling).
• Consider staged surgery or lesser procedure if clinically appropriate.
• Re-file appeal with new evidence or seek external review.

8. Patient experience & expectations

Patients undergoing medically indicated breast reduction report rapid improvement in pain and function (often within a few months), high satisfaction scores, and durable quality-of-life gains. Recovery typically takes several weeks to months; talk with your surgeon about expected downtime and risks.

If your insurer approves only partial coverage or asks for modifications, discuss clinical and financial tradeoffs with your surgeon and your insurer’s caseworker.

9. Quick checklist — what to assemble before submission

• Surgeon’s Letter of Medical Necessity (signed)
• PCP notes describing symptoms and impact
• Documentation of conservative therapy (PT notes, prescriptions, bra receipts)
• Preoperative photographs (front, side, oblique, ruler in photo)
• Estimated resection weight (grams per breast) and BSA/Schnur calculation
• Mammogram within insurer time window (if requested)
• Completed insurer precert / prior authorization forms

References & quick links

1. ASPS — Reduction Mammaplasty guidance (insurance & evidence)
2. Aetna clinical policy — Breast reduction / precertification info
3. Cigna policy — Reduction mammaplasty criteria
4. UnitedHealthcare — Breast reduction policy (InterQual references)
5. Systematic review / meta-analysis: reduction mammaplasty improves QoL and pain.
6. BREAST-Q outcomes & quality of life studies.
7. CMS / Medicare LCD — Reduction mammaplasty (coverage considerations)
8. HealthCare.gov — How to appeal an insurer decision (internal & external review).