Will Blue Cross Blue Shield Cover Breast Reduction?

Will Blue Cross Blue Shield cover any of the expenses of a Breast Reduction? I'm 19 years old, 5'1" tall and weigh 115 pounds. My cup size is a DD.

My back gets a few sharp pains in it and if I try to straighten out my shoulders so they don't slouch it hurts between my shoulder blades. My breasts make my body entirely unproportional so if you have any advice for anything I'd appreciate it!

Doctor Answers 46

Insurance covering Breast Reduction

BCBS in Texas is one of the best companies to approve breast reduction cases in our office experience. There are guidelines they go by such as amount of breast tissue to be removed from each breast. The symptoms they cover for are neck,shoulder,and back pain and intertrigia(growth under breast). Your doctor should be able to tell you in consultation if you have a good chance to get your case covered. Photos of your breast are submitted with your information. Turnaround time is usually 6 weeks. Go in early before the end of the year if you are planning to use your deductible so you can get your case approved and scheduled.

Dallas Plastic Surgeon
4.5 out of 5 stars 20 reviews

Blue Shield will most likely cover Breast Reduction

Most likely BC/BS will cover your surgery. Consult with a plastic surgeon (I recommend a board certified plastic surgeon by the American board of plastic surgery, the only board in plastic surgery by the American Board of Medical Specialties).

This doctor will examine you and document that you are a good candidate for the procedure. He will send a precertification (request for approval for surgery) letter to your insurance and after 4 to 6 weeks the insurance will respond, either approving or denying the surgery.

Victor M. Perez, MD, FACS
Kansas City Plastic Surgeon
5.0 out of 5 stars 14 reviews

Blue Cross

Blue Cross Blue Shield generally will cover a breast reduction if you meet their criteria.  Usually that includes, back and neck pain, rashes under the breasts, and large breasts (which are large enough).  If you have the right symptoms but the breasts aren't large enough, they may not approve the surgery.  Your surgeon will be able to tell you during your consultation if they are large enough to gain approval from BCBS.  

Allen M. Doezie, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 7 reviews

Insurance May Cover Breast Reduction

It is not possible to guarantee insurance coverage for breast reduction, but there are several factors that insurance companies typically use to evaluate reimbursement for breast reduction surgery: history of breast pain, neck-, back-, shoulder-pain, that haven't been relieved by medication, exercise, physical therapy; pain with exercise or interference with exercise; recommendation for breast reduction and documentaion by physical therapist, primary care doctor, orthopedic surgeon or neurosurgeon; the amount of breast tissue removed at surgery.
Be sure to check with your insurance company and submit documentation before surgery.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.5 out of 5 stars 14 reviews

Insurance and breast reduction

Insurance companies are getting harder and harder to work with, particularly for breast reduction to be covered. Some companies have started to exclude covering this surgery all together. I find this offensive and ridiculous.

BCBS should cover the surgery (and hopefully you've had it by now).

Hopefully you've found a good plastic surgeon to take care of you.

Insurnance coverage of breast reduction surgery

It is difficult to predict without more information whether your insurance company will cover the surgery.   Every insurance company has different requirements, and some companies will pre-authorize surgery while others will not.  In general, the insurance companies will want to know if you have back pain, neck pain, shoulder pain, shoulder grooving, and if you get rashes underneath your breasts.  They want to know if you have tried other things to alleviate your symptoms.  At the end of the day, one of the main things they care about is how much breast tissue is removed from each breast.   They sometimes use complicated formulas to come up with a weight that must be removed in order for the procedure to be covered.  

You can call your insurance company and ask about their specific requirements.

Samir S. Rao, MD
Chevy Chase Plastic Surgeon
5.0 out of 5 stars 12 reviews

Insurance coverage for breast reduction

Health insurance agencies will typically "cover" breast reduction operations if you adhere carefully and qualify based of their criteria. It may be helpful to call your health insurance provider and find out what their specific criteria may be. Each Insurance agency differs. Oftentimes quite a bit of documentation must be provided by you and your primary care physician to help prove that you have met the insurance criteria. A consultation with a plastic surgeon can also help you find out if you are a good candidate for breast reduction and if you are likely to be able to meet Insurance criteria. 

Rachel Streu, MD
Ann Arbor Plastic Surgeon
5.0 out of 5 stars 9 reviews

Will Blue Cross Blue Shield Cover Breast Reduction?

In general, approval from an insurance company for a breast reduction involves meeting several criteria. Each insurer will have a minimum resection volume (weight) of breast tissue that they consider constitutes a medically necessary reduction, often in the range of 400- 500 grams.   An experienced Plastic Surgeon can estimate the expected volume of resection. Some insurers use the Schnur Sliding Scale that is used to determine an appropriate cut-off for breast reduction resection weights based on the patient's height and weight. Some will use Body Mass Index as an exclusion criteria if the patient is deemed overweight resulting in large breasts Your best bet is to contact your insurer and find out what the specific criteria are for you.

In addition, in the approval process your doctor(s) should document persistent neck and shoulder pain, painful shoulder grooving from bra straps, frequent rashes of the inframammary fold, and frequent episodes of headache, backache, and nerve symptoms that are the result of large breasts.

Some insurers require a period (often 6 months) of conservative management for musculoskeletal symptoms with physical therapy, although this has not been shown to be a successful treatment. In addition, physical therapy will not address many of the other symptoms including bra strap grooving, rashes, inability to function social and in athletic endeavors to name a few. 

Photographs are a key component of the pre-authorization process. A picture can convey the true nature of the problem that might not be clear from the objective data submittted.

Unless you have other problems that might prevent you from having surgery, it sounds like you should be a good candidate. The sooner you see a Board Certified Plastic Surgeon, the sooner you can get your approval process going.

Good luck.

Bram Kaufman, MD
Cleveland Plastic Surgeon
5.0 out of 5 stars 7 reviews

Will insurance cover my breast reduction?

Insurance requirements vary from plan to plan and also within plan subtypes. The only way to know is to be evaluated by a plastic surgeon. If you are found to be a candidate for the surgery, a pre-authorization is submitted to the insurance to see if they "approve" it or not. Approval depends on the plan and it's requirements AND on whether or not they find it to be "medically necessary". Note that even if they approve it based on medical necessity, there is always a chance that they will deny it later since they state that "approval is not a guarantee of payment".
That being said, there are definitely factors that affect medical necessity. For example, if you answer yes to multiple of the following questions, there is a good chance that a good insurance plan will cover it, particularly when there are months of medical documentation to support it:

1. Have been to a doctor in the past 2 years to discuss pain due to large breasts and neck/shoulder/back pain?
2. Have you ever had an infection or rash under you breasts for which you have been to the doctor?
3. Have you ever been sent to physical therapy or a chiropractor?
4. Do you take medications often for the pain?
5.  Have you ever had xrays or an MRI of the neck or back?

Orna Fisher, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 8 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.