Empire Plan Insurance Coverage for Minors Getting Breast Reductions

There are many situations in which Empire Plan insurance coverage applies to breast reductions, but what about situations involving minors? That’s a question I occasionally get from concerned parents whose children are suffering from the pain and embarrassment of excessively large breasts. Luckily,  in many cases, coverage might be available.

Breast Reduction Basics with Empire Plan Insurance Coverage

Empire Plan insurance coverage typically applies to breast reduction surgery when a determination of medical necessity is made. That usually happens in one of three situations:

• Neck and back pain: The patient has ongoing, documented neck and back pain that doesn’t resolve with treatment such as support bras, physical therapy, medications, or other methods.

• Skin conditions: Individuals may have shoulder grooving or chronic skin conditions under their breasts that won’t resolve without surgical intervention.

• Symmetry post-mastectomy: A breast reduction would be covered to create symmetry for someone after a single (unilateral) mastectomy. This category may also fall under breast reconstructive surgery, which is covered by federal and state law.

Someone with one of the above issues may be considered a good candidate for breast reduction surgery.

This is also true for some individuals under 18. Many of the requirements for breast reduction surgery for minors under Empire Plan insurance coverage are the same as those for adults. However, one major caveat is that minors cannot consent to breast reduction surgery—consent must be from a parent or guardian. Some additional criteria are also used to determine if they are good candidates.

Special Considerations for Minors Getting Breast Reductions

Often, breast reduction surgery is performed on those older than 18, as it’s assumed that their breasts are done developing. However, there are some cases in which the surgery is necessary earlier. When I’m considering a minor for breast reduction surgery, this is what I usually look at:

• Physical maturity: Age is just a number—someone’s physical development age may not match what’s on their birth certificate. If someone is under 18 but their breast size has not changed for one year, it’s likely that breast development has ended, and surgery can be performed.

• Emotional maturity: Emotional maturity is also an important consideration. While breast surgery has come a long way when it comes to techniques and invasiveness, it’s still a major decision. Someone might be physically ready for breast reduction surgery but not emotionally developed enough to handle it.

• Overall health: Overall health is another important factor in whether a minor is a good candidate for breast reduction surgery. Of course, this applies to all patients. If someone is suffering from health issues, there will always be additional risks.

• Other treatment options: Similar to the adult category, what other interventions has the patient tried to manage their condition? The patient needs to show that they’ve exhausted other reasonable options to deal with the problem permanently.

• Activity level: Activity level applies to both the patient’s current activity level as well as to how the size of their breasts has affected it. A minor who has challenges doing school sports or other activities that they love due to their breast size may often be a good candidate for surgery.

These are just a few of the things I look at when I’m determining whether breast reduction surgery is appropriate for a minor patient. Surgery for minors may differ as well because breast tissue is typically denser in younger individuals, and the procedure has to be adapted for that. However, when it comes to medical necessity criteria, those are almost identical to what would be done for an adult.

While it’s true that minors may be able to get Empire Plan insurance coverage for breast reduction surgery, the best way to determine if your child might be a good candidate is to reach out to us to schedule a consultation.