Predicting Breast Reduction Resection Weights and Attainment of Insurance-Mandated Minimums

Abstract

Historically, third-party payers have used various criteria for insurance coverage approval of reduction mammaplasty in an attempt to stratify patients seeking surgery for cosmetic versus medical reasons. Third-party payers often required an arbitrary resection minimum that ranged from 350 to 500 g per breast before considering the procedure medically necessary as opposed to cosmetic in nature. 1,2 These arbitrary resection minimums for reduction mammaplasty placed smaller women at a disadvantage.In 1991, Dr. Schnur published an article that surveyed 92 plastic surgeons and found that 22% of breast reductions were performed for either mixed symptomatic/aesthetic reasons (17%) or purely aesthetic reasons (5%). 1 This was used to develop a sliding scale based on body surface area (BSA) that would theoretically discern symptomatic, mixed, and cosmetic motivations for surgery. Insurance companies have since adopted this scale and use the 22% cutoff as ammunition to deny insurance coverage for breast reduction,