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

Someone who is eligible for breast reduction surgery may have chronic neck and shoulder pain that doesn’t resolve with treatment.

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.

Medical Treatment Requirements

Schnur Sliding Scale Measurements

The pain must be clearly related to excess breast tissue weight, and there must be a minimum of three months of failed documented conservative treatment, including using special support bras, taking over-the-counter medication, completing physical therapy, or other treatment methodsMeeting the medical need is not enough alone. NYSHIP also considers the amount of breast tissue to be removed. There must be an adequate amount of breast tissue anticipated to be removed compared to the patient’s overall body mass. These criteria, which are measured and calculated on the Schnur sliding scale, are based on how much the plastic surgeon expects to remove. They are then submitted to the insurance company by the plastic surgeon. It may be possible that less will be removed during the surgery itself, but as long as the doctor has a reasonable expectation that’s in line with the Schnur scale, the criteria are met.

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.

Bringing Patient Advocacy to Breast Reduction and Reconstruction

Harris Plastic Surgery has a lot of insight when it comes to who is eligible for breast reduction under NYSHIP insurance. To learn more about improving your quality of life through reduction mammoplasty, contact us for a consultation. 

Stephen U. Harris, MD FACS

Dr. Stephen U. Harris is a board-certified cosmetic surgeon and recognized expert in breast reduction and reconstruction surgeries, having performed thousands in his career. When it comes to patient care, his philosophy is that every surgery should improve his patient’s overall quality of life, not just their appearance. Dr. Harris stays up-to-date on all the latest advancements in breast augmentation, reconstruction, and reduction and is a recognized innovator in the field. In fact, he was the first surgeon at Good Samaritan Hospital to offer primary prepectoral implant breast reconstruction, as well as secondary prepectoral revision surgery.

Dr. Harris also serves as Chief of Plastic Surgery at Good Samaritan Hospital in West Islip, New York and is an active staff surgeon (and former Chief of Plastic Surgery) at South Shore University Hospital in Bay Shore, New York.

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