Will Blue Cross Blue Shield Cover Breast Reduction?
- Asked by Kayla08 in Illinois
- 4 years ago
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!
Blue Cross/Blue Shield Policies Vary From State to State
Blue Cross/Blue Shield policies vary from state to state. Each state has different requirements requiring coverage for breast reduction surgery. Blue Cross/Blue Shield of Nebraska is very accommodating. They fully understand the benefits of breast reduction surgery. For that reason, they normally cover breast reduction surgery if the patient’s symptoms are sufficient. It is very important that your physician take a thorough history regarding the symptoms that are leading you to breast reduction surgery. Your surgeon will then send a letter outlining these symptoms and the amount of weight he or she expects to remove from your breasts. Normally, a photograph is also required. The photograph will not have your face on it. With this information the insurance company will make their determination as to whether or not they will cover your surgery.
Breast Reduction and Insurance
Blue Cross Blue Shield has different requirement depending on state and insurance plan. The process to receive insurance reimbursement for the breast reduction procedure can be quite frustrating. Moreover, different insurance companies generally have different requirements. There are a series of questions that must be answered prior to beginning the insurance process.
1. Have you experienced persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:
Pain in upper back
Pain in neck
Pain in shoulders
Painful kyphosis documented by X-rays
Pain / discomfort / ulceration from bra straps cutting into shoulders;
2. Have you had a mammogram within the last year?
3. Have you tried any of the following therapies for 3 months or more?
Supportive devices (e.g., proper bra support, wide bra straps)
Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
Physical therapy / exercises / posturing maneuvers
4. Have you seen a physician for the symptoms you have experienced? When?
Your physician must also be able to document symptoms such as back and neck pain, headaches, also needs to ensure that the estimated reduction is consistent with the insurance company’s requirements for your BMI.
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.
Recent Breast Reduction Reviews
Breast Reduction Photos
Reduction mammoplasty (breast reduction)
BCBS uses a scale called the schnur scale (http://www.bcbst.com/MPManual/The_Schnur_Sliding_Scale_chart.htm
to evaluate candidates for this procedure. Given your height and weight you have a body surface area of 1.5 which means that you should have at least 260 grams from each breast to be removed in order to be considered eligible for coverage. This is the equivalent of approximately 6-7 ounces.
Will BC/Bs cover breast reduction
Coverage for a breast reduction depends on the state your insurance is through. The blues can be strict on what they allow as medically necessary. Their rules are typically under 180 pounds, larger than a DD, and have tried conservative physical therapy to help alleviate the back and shoulder discomfort non surgically.
Insurance Coverage by BCBS
Some Insurance companies do cover breast reduction surgery, but there are certain variables and criteria that must be met. This is unknown until a consultation with a Doctor is made and criteria is met. The Insurance companies will either approve or not according to signs and symptoms of the patient's request for Breast Reduction Surgery.
Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.
Blue Cross Blue Shield Coverage for Breast Reduction Varies from State to State
Breast reduction surgery is often covered by insurance carriers, but not all of them cover this procedure and significant restrictions may exist. Some insurance companies actually exclude breast reduction as a contract exclusion. When insurance carriers cover breast reduction, they may have specific criteria that must be met.
For instance, most insurance carriers require documentation of symptoms. Examples would include back pain, shoulder pain, breast pain, and headaches to name a few. They may also require documentation of attempted non-surgical management of symptoms. Examples might include physical therapy, support devices, and anti-inflammatory drugs. Some insurance carriers require a minimal amount of breast tissue removal from each breast. This is often based on calculations, which utilize the patients’ weight and height.
The process starts with a consultation. At that time, pictures are taken and prior authorization letter is sent for approval. It typically takes about six weeks to obtain a response. If your insurance carrier’s criteria are met, you are ready to schedule surgery. Blue Cross Blue Shield’s criteria varies from state to state, but in our location (Nebraska), they have a high-approval rate.
Insurance coverage for Breast Reduction
Some insurance carriers still cover breast reduction procedures, a pre authorization letter will need to be submitted by your plastic surgeon to determine coverage. Blue Cross/Blue Shield is one of the better carriers.
Will Blue Cross Blue Shield Cover Breast Reduction
Depending upon the specific policy, Blue Cross may cover your breast reduction. However, the precertification and benefits department must be contacted first to see if you are covered. The insurance company coverage varies from state to state so it is best to have the coverage reviewed.
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.