Insurance Guide
EmblemHealth often covers breast reduction and lift for patients with symptomatic macromastia, meaning large, heavy breasts that cause physical discomfort.
This guide explains EmblemHealth’s medical necessity requirements for breast reduction, how much breast tissue may need to be removed, and how we handle insurance preauthorization for breast reduction and lift at Kiwanuka Plastic Surgery in New York City.
Summarized from EmblemHealth Medical Policy MG.MM.SU.01g, Breast Reduction Mammoplasty, last reviewed April 10, 2026. Insurer policies change, and your plan documents control.
EmblemHealth publishes its criteria in Medical Policy MG.MM.SU.01g, Breast Reduction Mammoplasty. Breast reduction is considered medically necessary when all of the following are documented.
If you are 40 or older, or younger with a mother, sister, or daughter who had breast cancer, EmblemHealth also asks for a mammogram negative for cancer within two years of surgery.
EmblemHealth uses the Schnur scale, a chart that pairs your body surface area, calculated from height and weight, with a minimum amount of tissue removed per breast. Your estimate is reviewed before surgery.
Minimum tissue removal per breast from the Schnur scale. Our team checks your measurements against EmblemHealth's policy before your consultation. See the full Schnur scale and calculator.
Our team works with EmblemHealth members every day. More than 95% of the insurance requests we submit are approved. Here is how the process works.
Our team
We check your plan's benefits, deductible, coinsurance, and referral rules at no cost.
You and Dr. Kiwanuka
Dr. Kiwanuka examines you and plans your reduction. Consultations are complimentary for insurance patients.
Our team
Clinical photographs, records of prior treatment, and a letter of medical necessity written to EmblemHealth's criteria.
Our team
We submit your request to EmblemHealth and follow up until a decision is made.
All patients photographed with informed written consent. Individual results vary and are dependent on anatomy, procedure type, and recovery.
Often, yes. EmblemHealth covers breast reduction when it is medically necessary: breasts large enough to cause physical symptoms for at least one year that have not improved with treatment. Your symptoms, photographs, and planned tissue removal must meet EmblemHealth's policy, and your plan must include the benefit.
EmblemHealth Medical Policy MG.MM.SU.01g asks for age 18 with growth complete; symptoms from breast size for at least one year, such as upper back or neck pain, rashes, or nerve symptoms; symptoms that limit daily activities or exercise; front and side photographs; and tissue removal at or above the Schnur scale minimum for your body surface area.
Yes. EmblemHealth uses the Schnur scale, based on body surface area, and reviews your estimated tissue removal before surgery. You can estimate your number with our Schnur scale calculator.
Yes, if you are 40 or older, or younger with a mother, sister, or daughter who had breast cancer. EmblemHealth asks for a mammogram negative for cancer within two years of surgery.
Yes. Every breast reduction reshapes the breast and moves the nipple higher, so the lift is part of the operation. A lift on its own, without a reduction, is generally considered cosmetic.
Our team checks your EmblemHealth benefits for free before you schedule and explains your coverage. You may request a written estimate of what we will bill at any time.
Yes. For upper back or neck pain, EmblemHealth asks that pain has not improved with pain relievers and anti-inflammatory medication, and that symptoms have been present for at least one year.
We review the reason and, when appropriate, send more documentation or an appeal. You also have appeal rights through EmblemHealth, and some denials qualify for an independent external review.
Share a few details and our team will check your breast reduction benefits at no cost and with no obligation. Prefer to write? Contact us.
Verification confirms your benefits. It is not a guarantee of coverage or payment.