If you live in Westchester County, you know how full a day can get. Between work, family, and everything in between, the last thing you need is neck, back, and shoulder strain from breasts that are too large for your frame. Many of my patients from Yonkers, Scarsdale, White Plains, Bronxville, and Rye tell me the same thing. They have lived with this discomfort for years, and they assume their health insurance plan will never help.
If you are covered by the NYSHIP Empire Plan, I want you to know your situation may be different than you think. A breast reduction, known medically as reduction mammaplasty, is the surgery that removes excess breast tissue, while reshaping and lifting the breasts. When the true purpose of the surgery is to relieve or improve physical symptoms, it is treated as a medically necessary procedure. That means it is often covered by your insurance plan.
I am Dr. Scott Newman. For over thirty years, I have focused my practice on surgery of the breast and body. I have performed more than 7,000 breast procedures, I am one of the most experienced Breast Plastic Surgeons in the country. My goal on this page is to explain, in plain terms, how Empire Plan coverage works and how to get started.
Wondering If Your Empire Plan Case Qualifies?
I would be glad to review your symptoms and explain how your Empire Plan benefits may apply to a medically necessary breast reduction. Call my Westchester office at (914) 423-9000 or Request a Consultation to get started.
Does the NYSHIP Empire Plan Cover Breast Reduction?
Yes. The NYSHIP Empire Plan typically covers breast reduction when the surgery is medically necessary. “Medically necessary” means the procedure treats a documented health problem, not just a cosmetic concern about appearance.
Here is a detail many patients miss. The Empire Plan’s Medical/Surgical Program is administered by UnitedHealthcare. That means UnitedHealthcare’s medical-necessity criteria are the rules your case is measured against.
Because those rules can feel confusing, my team spends real time helping you understand them. For patients with Empire Plan insurance who medically qualify for Breast Reduction surgery, I can almost always obtain approval with my initial request.
What Makes a Breast Reduction Medically Necessary Under the Empire Plan?
A medically necessary breast reduction is one that treats real physical problems caused by the weight and size of your breasts. This is very different from a procedure chosen only to change appearance. Reviewers look for symptoms that have lasted over time and have not improved with other care.
These are the functional problems I document most often for my patients.
Chronic Neck, Back, and Shoulder Pain
- Key point: Ongoing pain, in the neck, upper back, and shoulders, is one of the most common reasons patients seek a reduction.
- Key point: Reviewers want to see that this pain has continued despite conservative care, such as physical therapy or supportive garments. It’s also important to document if you have been using any medications to treat your pain or discomfort. Even over-the-counter medicines are important to document.
Skin Irritation and Shoulder Grooving
- Key point: Recurring rashes or irritation in the fold under the breasts can signal a functional problem.
- Key point: Grooves in the shoulders from bra straps show the physical load your body carries every day.
Nerve Symptoms and Restricted Activity
- Key point: Numbness or tingling in the hands and arms can be linked to breast weight and posture strain.
- Key point: Trouble exercising or doing daily tasks helps show how these symptoms affect your life.
A reduction can relieve or improve these symptoms for many patients, though results vary from person to person. Which of these apply to you is a good question to bring to your consultation, where I can review your history in detail. These are the medical indications for surgery. The Empire Plan typically covers Breast Reduction surgery as a treatment for these medical issues.
Understanding the Schnur Scale and Tissue Removal
Insurance reviewers often use a tool called the Schnur scale. In plain terms, the Schnur scale uses your body surface area, a combination of your height and weight, to calculate the amount of breast tissue that needs to be removed. It helps confirm that the reduction is substantial enough to be reconstructive and medically necessary, rather than elective.
I calculate this estimate during your consultation, based on your measurements and your goals. It is one clinical detail among several, not the whole story.
Every patient is different, and exceptions may be considered case by case. If you are close to a threshold or unsure where you fall, that is exactly the kind of question I can help answer when we meet.
What Documentation Does the Empire Plan Require?
Approval depends heavily on documentation. The stronger your record, the smoother the review tends to go. Reviewers want to understand that your symptoms are real, long-lasting, and not helped by other treatments.
Here is what a typical documentation packet includes.
- Symptom history: A record of your neck, back, and shoulder complaints over time.
- Conservative treatment history: Evidence that other care did not resolve your symptoms, such as physical therapy, supportive garments, or skin treatments.
- Clinical photographs: Standard photos that show your anatomy for the reviewer.
- Letter of medical necessity: A letter from me explaining why surgery is appropriate for your case. This letter is typically something that I will write as part of your packet.
- Pre-authorization: Approval from the plan before surgery. Pre-authorization means the plan agrees, in advance, that the procedure meets its criteria.
Once you come to my Westchester office, my team assembles and submits the pre-authorization packet for you.
In-Network vs. Out-of-Network Care for Westchester Patients
Two terms come up often, so let me define them. An in-network provider has a contract with your plan. An out-of-network provider does not have that contract, which can change how your benefits apply.
In-network care has a limited number of doctors, most of whom have general practices. Out-of-network care can widen your choice of surgeon. The right path depends on your plan and your priorities. In many cases with the Empire Plan your costs may be lower, or even zero, depending on your particular benefits.
| In-Network | Out-of-Network | |
| Contract with plan | Yes | No |
| Typical cost sharing | Lower | Depends on Plan |
| Surgeon choice | Limited to network | Broader |
Patient protections exist that limit surprise billing at in-network facilities, which can offer peace of mind. Confirming how your Empire Plan benefits apply is a smart early step, and my office helps Westchester patients do exactly that.
Where Your Breast Reduction Surgery Takes Place
Patients often ask me where the surgery itself happens. When your breast reduction is covered by insurance, it is performed at the hospital. This is an answer I rarely see addressed clearly, so I want to be direct about it.
The hospital setting brings coordinated care, on-site support, and the resources of a full surgical team. For an insured, medically necessary procedure, that is where I operate.
You do not need to arrange this yourself. My team coordinates the hospital scheduling as part of guiding you through the process.
What If Your Claim Is Denied?
An initial denial can feel discouraging, but it is common and it is not the end of the road. Reviewers often ask for more information rather than closing the door for good.
Many cases succeed after additional documentation and a formal appeal. An appeal is a request for the plan to review its decision, usually with stronger supporting evidence.
You will not face this alone. My team supports the appeal process, gathering what the plan needs and making the case for medical necessity on your behalf.
How to Start the Process With Dr. Newman
Getting started is simple when you have local guidance. Here is the path I recommend for Westchester patients.
- Book a consultation. Schedule a visit at my Westchester office.
- Get evaluated. I review your symptoms, examine your anatomy, and calculate your Schnur scale estimate for medical necessity.
- Gather documentation. We help you pull together your symptom history, conservative treatment records, and photos.
- Let my team handle pre-authorization. We assemble and submit your packet to the plan and coordinate next steps.
If large breasts are affecting your comfort and daily life, I would welcome the chance to talk with you. Reach out to schedule your consultation, and let’s review whether your Empire Plan case may qualify.
Related Procedures
If you are researching a breast reduction, you may also want to learn about related procedures I perform. Each has its own candidacy criteria, which we can review together during your visit.
Frequently Asked Questions
Does the NYSHIP Empire Plan cover breast reduction surgery?
Yes, the NYSHIP Empire Plan may cover a breast reduction when it is medically necessary and meets the plan’s criteria.
Who administers the Empire Plan’s medical and surgical benefits?
The Empire Plan’s Medical/Surgical Program is administered by UnitedHealthcare, so UnitedHealthcare’s medical-necessity criteria apply to a breast reduction claim.
What symptoms make a breast reduction medically necessary?
Ongoing neck, back, and shoulder pain, skin irritation under the breasts, shoulder grooving from bra straps, and nerve symptoms that limit daily activity are the functional problems reviewers look for.
What is the Schnur scale?
The Schnur scale compares your body surface area to the amount of breast tissue removed, helping confirm the reduction is substantial enough to be reconstructive rather than elective.
What documentation do I need for Empire Plan approval?
You typically need a symptom history, evidence of failed conservative treatment, clinical photographs, and a surgeon’s letter of medical necessity, all submitted with your pre-authorization request.
Do I need pre-authorization before breast reduction surgery?
Yes, the Empire Plan requires pre-authorization, which means the plan must approve that your procedure meets its medical-necessity criteria before surgery takes place.
Where is an insurance-covered breast reduction performed?
An insurance-covered breast reduction is performed at the hospital, where a full surgical team and coordinated care are available.
What happens if the Empire Plan denies my breast reduction?
An initial denial is common and often reversible, since many cases are approved after additional documentation and a formal appeal that my team helps you prepare.
Can Westchester patients see Dr. Newman for a breast reduction consultation?
Yes, Dr. Newman sees Westchester patients at his Yonkers office and also offers consultations at the Manhattan and Long Island locations.