Being a New York plastic surgeon’s office that caters to many public sector employees, we often are asked, “Does NYSHIP cover breast reduction surgery?” Many individuals with large breasts have suffered from neck and back pain for years and are surprised to learn that their insurance policy may offer a way to fix the issue. However, NYSHIP only covers breast reduction surgery in specific situations. Here, we provide guidance on when this surgery is likely to be approved for coverage by your NYSHIP Insurance plan.
Does NYSHIP Cover Breast Reduction in Certain Scenarios?
According to NYSHIP’s policy language, there are situations in which breast reduction surgery is considered medically necessary. Medically necessary is a subjective term mainly used to describe surgeries that are not purely aesthetic and correct functional or structural problems. They’re done because the patient suffers from chronic symptoms that cannot be resolved without surgery. The table below lists some common conditions that make your procedure more likely to be covered by NYSHIP as a medically necessary procedure.
| Conditions That Indicate Breast Reduction is a Medical Necessity | |
|---|---|
Chronic Pain | Severe neck, shoulder, or back pain, which leads to a reduced quality of life. |
Skin Irritation and Infections | Friction and moisture under the breasts can cause rashes, irritation, and infections that are hard to treat, even with standard medical interventions like lotions or prescriptions. |
Restricted Mobility | Discomfort from large breasts that limits physical activity, impacting physical and mental health. |
Emotional Distress | Excessively large breasts can cause physical challenges that lead to low self-esteem, interfere with social interactions, and harm mental health. |
Posture Problems & Nerve Compression | The added weight of large breasts causes poor posture, shoulder grooving, and nerve compression, leading to numbness and tingling in arms. |
To give you a better example, consider the two scenarios listed below. One scenario is an example of a surgery that NYSHIP would likely cover. The other is one where coverage probably wouldn’t be extended.
| Breast Reduction Coverage Case Scenarios | |
|---|---|
Possibly Covered | Monica has large breasts that have caused her to slouch most of her life. When she entered her late 30s, she started to develop chronic neck and back pain and has suffered with it for more than a year. She’s under the care of a physician and has tried physical therapy, special support bras, lifestyle changes, medication, and even pain-blocking injections. However, none of these have resolved her chronic pain, and her doctor believes that it is very unlikely it will resolve without surgical intervention. This is a fairly classic scenario in which NYSHIP does cover breast reduction surgery. |
Coverage Unlikely | Alice is dissatisfied with the appearance of her breasts. She has B- or small C-cup breasts, and she’s noted that the breasts have sagged after breastfeeding her children. She’s not suffering from any chronic pain in her neck and back, nor is she seeking treatment. Her main goal is to lift the breasts and see more fullness in the upper pole of her breasts. Surgically, the breast size needs to be maintained or even enhanced to achieve her goals. While there would be some physical benefit to Alice getting breast lifting surgery, her primary motivation is aesthetic, and as a result, the surgery likely wouldn’t be covered. |
These two scenarios highlight classic motivations for breast reduction surgery as well as situations in which insurance considers it medically necessary. When it’s deemed medically necessary, the surgery will likely be covered, but like with most other medical treatments, it won’t be covered in full.
What Am I Responsible For?
If your surgery is approved because it’s considered medically necessary, that doesn’t mean you will escape all out-of-pocket costs. Your copay, coinsurance, and deductible costs will affect how much you pay for this surgery versus how much your insurance covers:
Copays | Coinsurance | Deductible |
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So, does NYSHIP cover breast reduction? Yes, but it’s difficult to say what your out-of-pocket costs will be until you’ve met with a doctor. There are a lot of different surgical methods, and the type of surgery will change the overall cost. To receive more details about when NYSHIP covers breast reduction, schedule a consultation.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
Harris Plastic Surgery works with NYSHIP and other insurance plans in covering breast reduction surgery for cases in which it’s medically necessary for patients. If you’re still wondering “Does NYSHIP cover breast reduction in my case?” contact us online or by phone/text. Or you can schedule your consultation today!
Joanne Parrinello, Practice Manager
Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.
