Who is Eligible for Breast Reduction Under NYSHIP Chronic Pain Criteria?

As a Long Island plastic surgeon, I’m often asked to weigh in on who is eligible for breast reduction under NYSHIP insurance. Many of my patients are teachers or public sector workers who have suffered for a long time due to the weight of their breasts. In just about all of their cases, I consider breast reduction medically necessary. Unfortunately, NYSHIP sometimes has a different idea. They have specific criteria that they demand patients meet. Understanding what they look for can help you determine if you are eligible.

How Breast Size Causes Chronic Pain (and How Surgery Helps)

Many of the women who come into our office to talk about breast reduction surgery are in their 30s, 40s, and 50s. They’ve had large breasts all their lives, but only now have they started to notice pain. At first, they may write off that pain as the effects of growing older or the result of sleeping wrong. But over time, no matter what they do, the pain gets worse because their condition is getting worse. This is a problem that builds upon itself. The weight of the patient’s breasts pulls on their chest wall and spine, causing them to hunch forward. Slowly, that poor muscle memory becomes part of their posture, exacerbating the problem. Meanwhile, as we age, our spines degenerate, creating even more pain. Finally, chronic pain leads to a decrease in activity, resulting in even poorer overall health.

Patients may experience significant shoulder, neck, and back pain—but that’s not all. Many nerves in the trunk of the body can be impinged and affected by the weight of large breasts. Patients may suffer from tension headaches, numbness and tingling in their arms and hands, and a host of other issues.

A reduction mammoplasty—breast reduction—helps to correct that issue. By removing excess tissue, fat, and skin, we’re able to take the weight off your shoulders. Following surgery, patients enjoy an immediate reduction in their pain. In the long term, their overall quality of life improves as their posture, physical activity level, and balance recover.

For chronic pain sufferers, breast reduction surgery can be life-changing. Of course, it can also be expensive. Luckily, if you’re suffering from chronic pain due to large breasts and you have NYSHIP plan insurance, your procedure may be covered under your plan.

Chronic Pain Criteria for Who is Eligible for Breast Reduction

NYSHIP insurance may cover breast reduction surgeries that are deemed to be medically necessary. There are a few different conditions in which this happens, and chronic pain is one of them. From an insurance perspective, medical necessity is determined based on a two-pronged approach related to medical history and the amount of breast tissue to remove.

You will also need to submit documentation that proves failed conservative treatment. That could include medical records with your primary care physician, physical therapy notes, specialist visits, and imaging. All of these details back up the fact that your breast reduction surgery is medically necessary.

Of course, no one can tell you for sure who is eligible for breast reduction under NYSHIP criteria without a consultation. All decisions are made on a case-by-case basis and require the input of a qualified, experienced, and knowledgeable plastic surgeon who specializes in these procedures. To determine if you might be eligible for breast reduction surgery, it’s important to meet with one in person.