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 (40)

Breast Reduction and Insurance

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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
Headaches
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.


West Palm Beach Plastic Surgeon
4.5 out of 5 stars 20 reviews

Blue Shield will most likely cover Breast Reduction

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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 8 reviews

Breast reduction covered by insurance?

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Yes, insurance covers breast reduction. It can be challenging to get pre-authorization from the insurance company, and I have found it is particularly difficult, if not impossible the in young patient. It is worth a try, but be prepared to pay cash. See attached web reference for an 18 year-old that was approved and paid for by her private insurance company. Thanks for sharing.

Joel Patrick Maier, MD
Cincinnati Plastic Surgeon
5.0 out of 5 stars 12 reviews

Will insurance cover my breast reduction?

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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
4.0 out of 5 stars 5 reviews

Probably

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It sounds like you would be able to get your surgery covered by insurance because of the pain you're feeling. Consult with a board certified PS who will examine you and make sure breast reduction is right for you. They will then help you get insurance approval. 

Insurance coverage of breast reduction varies by company

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Each company has different requirements for covering breast reduction.  But they all look at similar factors.
  • Do you have symptoms caused by having large breasts?  These include neck and back pain, grooving in your shoulders from your bra strap, breast pain, and rashes under the breasts.
  • Have you tried nonsurgical treatment for these symptoms?  This may include over-the-counter or prescription pain medication, seeing a chiropracter, physical therapy, wearing a sports bra, using ice or hot packs, and using topical creams for any rashes.
  • Have other causes of these symptoms been ruled out?  Your primary care doctor can assess this for you.
  • Will enough tissue be removed?  Every insurance company has a different minimum number, and it varies by your height and weight as well.  Your plastic surgeon will estimate this number during your consultation.
A quick call to your insurance company can help you find their specific requirements.  

Jennifer Greer, MD
Cleveland Plastic Surgeon
5.0 out of 5 stars 4 reviews

Breast reduction covered by insurance

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Depending on your situation, insurance may be able to subsidize the cost of breast reduction. Some breast reduction coverage requirements where I practice in Ontario include your current cup size, the amount of breast tissue removed during surgery, unsuccessful experiences with alternative treatments and medications, as well as recommendations for breast reduction from other specialists, such as chiropractors and neurosurgeons.

Only way to find out is to ask

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Every insurance plan has different requirements, even within BC/BS.  The only way to find out is to have a board certified plastic surgeon write a letter of preauthorization to the insurance company and have them check your individual policy.

Insurance coverage for Breast Reduction

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It is difficult to say for sure whether your insurance will cover your reduction. Insurance companies have made it more difficult to get coverage over the last 20 years by increasing the amount of tissue that needs to be removed and adding other body mass index requirements. Also every insurance policy is different and some do not cover breast reductions at all. Best to see an experienced Plastic Surgeon and they can help you find out if your surgery might be covered..

G. Wesley Price, MD
Bethesda Plastic Surgeon
5.0 out of 5 stars 4 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.