While some individuals pursue breast reduction for cosmetic reasons, many others undergo the procedure to achieve a breast size that’s not only more proportional to their body but also addresses medical concerns. Medically necessary breast reductions help remedy physical discomfort, functional limitations, and other health concerns caused by excessively large breasts.
Understanding What Is Considered a Medically Necessary Breast Reduction
Breast reduction surgery is deemed medically necessary when large breasts (macromastia) cause significant physical or psychological distress that interferes with daily life and cannot be alleviated through non-surgical interventions.
Common Symptoms and Complications of Macromastia | ||
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Functional Limitations | ||
Posture Concerns | Nerve Compression | Emotional Distress |
Medically necessary breast reduction is a well-established procedure with high success rates and significant benefits for patients. The surgeon evaluates the patient’s medical history, symptoms, and physical condition. Preoperative photos and measurements are typically taken to document the severity of macromastia. Many insurance providers cover breast reduction surgery when deemed medically necessary. Patients may need to provide documentation of symptoms, failed conservative treatments, and the surgeon’s recommendation.
Medical Criteria and Evaluation Process for Breast Reduction Surgery
To qualify for a medically necessary breast reduction, patients must typically demonstrate that their breast size is causing significant health issues that affect their daily lives. Persistent physical symptoms such as chronic back, neck, or shoulder pain that does not respond to medication or physical therapy, skin irritation or recurrent infections beneath the breasts, and postural problems or musculoskeletal complaints are common criteria.
In addition, patients are usually required to have attempted non-surgical treatments, including the use of supportive bras or custom-fitted garments, physical therapy to alleviate pain, or weight loss efforts (if applicable) to reduce breast size.
Insurance companies often mandate a minimum amount of tissue removal based on the patient’s body surface area or the Schnur Sliding Scale. You will also need detailed documentation from healthcare providers, including medical records that outline symptoms, attempted treatments, and referrals, for preapproval from your insurance provider.
Insurance Coverage Criteria for Medically Necessary Breast Reduction
Insurance providers often require patients to meet specific criteria to approve coverage for medically necessary breast reduction. The following table outlines common requirements:
Insurance Coverage Criteria | |
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Insurance Criteria | Explanation |
Documented symptoms | Chronic pain, skin conditions, or functional impairments caused by large breasts. |
Non-surgical treatments | Evidence of attempted interventions like physical therapy, weight loss, or medication. |
Photographic evidence | Preoperative photos demonstrating macromastia and related issues. |
Tissue removal requirements | Minimum amount of breast tissue (e.g., 300-500 grams per breast) to be removed. |
Surgeon’s evaluation | Letter detailing medical necessity based on symptoms and physical exam. |
The Evaluation Process
The evaluation process for medically necessary breast reduction involves several steps. It begins with an initial consultation with a primary care physician to discuss symptoms and their potential causes, followed by referrals to specialists such as orthopedic doctors or dermatologists if needed. It is not unusual for patients to seek consultation with a board-certified plastic surgeon as a first step. They will serve as the “captain of the ship,” coordinating care and communicating with the primary care providers who may have suspected that breast reduction would be medically helpful. A board-certified plastic surgeon then assesses the patient’s breast size, tissue volume, and overall health, documenting the medical necessity of the procedure and estimating the required tissue removal. Patients may also need to complete non-surgical interventions such as physical therapy or pain management before proceeding.
To obtain insurance pre-authorization, detailed medical records, photographs, and the surgeon’s notes are submitted for review. Once all criteria, including tissue removal requirements, are met and the insurance company approves the procedure, the surgery is scheduled, and pre-operative preparations begin.
See If You Qualify for a Medically Necessary Breast Reduction
Medically necessary breast reduction is a life-transforming procedure that addresses both the physical and emotional challenges caused by overly large breasts. This surgery can significantly enhance your quality of life by reducing pain, improving mobility, and restoring your self-confidence. For individuals struggling with the burdens of excessively large breasts, consulting with our qualified team and expert surgeon and exploring your insurance coverage can help you achieve relief and comfort in your day-to-day life.
Harris Plastic Surgery - Your Breast Reconstruction Experts
If you think you might qualify for a medically necessary breast reduction, we are here to help. Schedule your consultation today, contact us online, or by phone/text if you have any additional questions for our team.

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.