Medically Necessary Breast Reduction: NYSHIP Requirements for Skin Conditions

Medically necessary breast reduction surgery may be indicated for chronic skin conditions like shoulder grooving with ulcerations.

When most people think of medically necessary breast reduction surgery, the first thought that comes to mind is chronic neck and back pain. After all, it’s very easy to make the connection between breast weight and this type of pain. What’s less obvious, however, are the skin conditions that can be caused when you have excessive breast tissue. Luckily, NYSHIP insurance provides coverage when skin conditions make breast reduction surgery medically necessary.

Medically Necessary Breast Reduction for Skin Conditions 

Many of my patients for medically necessary breast reduction surgery come to me very confused about the language of their insurance policy. NYSHIP insurance does cover breast reduction surgery when you have a covered chronic skin condition; however, the section that explains it is very unclear. Specifically, the policy states that candidates for breast reduction surgery must have:

Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy. 

For clarity, I will provide you with a few definitions that will make this section a little bit easier to understand.

  • Submammary: This refers to the skin under the breasts.

  • Intertrigo: This is a condition that occurs in skin folds and is characterized by red, inflamed, and itchy rashes. In the worst cases, the skin can break open and lead to infections.

  • Refractory to conventional medications and measures: This means that the condition is not responding to conventional treatments like lifestyle changes, creams, special bras, medication, and other non-invasive approaches. 

  • Shoulder grooving with ulceration: Shoulder grooving is a separate type of skin condition that occurs when the bra strap or other article of clothing presses into the skin regularly, causing a groove or indentation. In extreme circumstances, this can lead to ulceration, where the skin breaks open and develops painful sores. 

  • Unresponsive to conventional therapy: Conventional therapy used to resolve shoulder grooving typically involves adjusting the fit of the bra or using special types of padding to reduce pressure on the affected area. However, when the breast tissue is extensive, these methods of intervention typically don’t work.

To summarize, NYSHIP insurance may cover medically necessary breast reductions for skin conditions in two scenarios: when someone is suffering from chronic rashes under the breasts or chronic ulcers under the bra strap. Many patients suffer from both conditions. 

NYSHIP Requirements for Coverage Related to Skin Conditions

While having a skin condition related to the size of your breasts may prove that breast reduction surgery is medically necessary, NYSHIP has other breast reduction standards in place that individuals will also have to meet. Some common criteria they look for include:

 

NYSHIP Criteria for Breast Reduction Coverage

Statement of Medical NecessityA plastic surgeon will have to complete a thorough evaluation to determine if it’s reasonable that surgery would resolve your current symptoms. The surgeon will do a complete exam, collect your medical history, and may complete imaging to determine if your condition is connected to the size of your breasts. If it is, and the surgeon believes surgery would resolve it, they will notify your insurance company that it is a medically necessary procedure and that it should be covered. These criteria are very similar to the criteria for getting breast reduction coverage for chronic neck and back pain.
Schnur Scale MeasurementsInsurance companies also have objective criteria in place to determine when breast reduction surgery is medically necessary. Specifically, they follow something called the Schnur scale. Your plastic surgeon will provide information regarding your overall body surface area compared to the amount of breast tissue to be removed. If the measurement falls within the Schnur scale standards, then the insurance company may consider it medically necessary.
Conservative TreatmentThe insurance company may also require proof that you’ve tried other noninvasive means of resolving the skin condition. Notes from your primary care provider, prior prescriptions, imaging and testing you’ve had done, and other medical records can all be used to show that you’ve made a good-faith effort to resolve the issue without surgical intervention.

Skin conditions aren’t the only situations in which breast reduction may be considered medically necessary. Some patients who seek it out suffer from chronic pain conditions like neck and back pain or thoracic outlet syndrome. Excessive breast tissue can lead to many different medical problems that can only be corrected with surgery—skin conditions are just one of them.

If you believe that medically necessary breast reduction surgery may help resolve your chronic skin condition, you should reach out to a plastic surgeon. They will be able to give you a detailed consultation and examination to see if reduction mammoplasty might be the surgery you need. 

Bringing Patient Advocacy to Breast Reduction and Reconstruction

Harris Plastic Surgery provides a detailed consultation for patients seeking medically necessary breast reduction surgery under their NYSHIP insurance. To learn more, 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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