Can a Minor Get a Breast Reduction? Empire Plan Coverage Considerations

A minor can get a breast reduction under many insurance plans when they meet criteria related to macromasti

In medically necessary cases, a minor can get a breast reduction to deal with physical pain connected to their chest size. But there’s nothing minor about breast reduction surgery—especially when it’s being performed on someone under 18. This is a big decision to make. While your plastic surgeon should go over all of the risks and benefits with you and your child, it’s also important to understand how insurance like the Empire Plan is going to play in. If you believe your child would be a good candidate for breast reduction surgery, this is what you need to know. 

Situations in Which a Minor Can Get a Breast Reduction 

When adult women get their breast reduction surgeries approved, it’s usually related to ongoing pain or physical limitations due to their breast size. For minor patients, it’s a bit more complicated because they’re not done growing yet. Insurance won’t typically pay for a surgery that may have to be repeated in a few years, and doctors also don’t want to perform repeat surgeries.

With that said, one of the biggest considerations for when a minor can get a breast reduction is breast size stability. If a patient under 18 has not had a breast size change in a year or more, typically that means development is done, and the size is stable enough to do surgery. However, there may be times when surgery should be performed even if growth continues.

This is often done in minors when they’re diagnosed with macromastia, a condition marked by excessive breast tissue growth. In older women, macromastia might result from weight gain, pregnancy, or taking certain medications. In patients under 18, it’s usually related to hormones. Puberty triggers the macromastia, and that macromastia leads to chronic pain or skin conditions under the breasts.

The criteria for a minor getting a breast reduction are very similar to those of an adult. There has to be some type of chronic pain or condition directly related to the size of the patient’s breasts that can’t be resolved with reasonable conservative treatment. That’s the criteria the doctor uses, and it’s also mainly the criteria insurances like the Empire Plan use. 

Insurance Criteria for Breast Reduction Surgery for Minors

Getting insurance coverage for a minor getting a breast reduction is a bit less of a hurdle to clear than for an adult. When a minor has pain related to macromastia, it’s easy to connect the two issues, while an older person may not realize their breast size has been causing them issues for years. It can be a lot more convoluted to prove the causal relationship.

People under 18 don’t have as much of a medical history and have had less time to “grow into” the weight of their chests. What insurance companies are concerned about when they’re deciding whether to cover breast reduction surgery is the amount of breast tissue that is expected to be removed during surgery compared to the patient’s overall body mass. These criteria are measured on something called the Schnur Sliding Scale. While this sounds complicated, it’s actually pretty straightforward.

One thing to note is that the chart tops out at 1,000 grams, or 1 kilogram. That means that just about anybody with that amount of breast tissue to be removed would meet the standard. Also, the measurement is based on how much the plastic surgeon anticipates will be removed during the surgery. It’s always possible that the number will be less post-surgery, but estimates made in good faith are usually covered.

That scale makes up half of the criteria for getting breast reduction surgery approved under NYSHIP insurance. The other half is showing some type of physical condition related to the size of the patient’s breasts. That’s done through doctor’s notes, treatment records, and plastic surgeon recommendations.

Of course, that’s just the basic insurance criteria for when a minor can get a breast reduction. There are a lot more questions to ask that can’t be answered online. The best way to determine if a breast reduction is right for your child is to connect with a qualified plastic surgeon for consultation. 

Bringing Patient Advocacy to Breast Reduction and Reconstruction

Harris Plastic Surgery can help you decide if a breast reduction is right for your child. To schedule a consultation with Dr. Harris,

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.

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