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 (31)

Breast Reduction and Insurance

+2

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 16 reviews

Blue Shield will most likely cover Breast Reduction

+2

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 7 reviews

Breast Reduction Insurance Coverage Varies

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. Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 45 reviews

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Will insurance cover Breast Reduction Surgery?

+1
Blue Cross/Blue Shield and some other insurance companies will cover Breast Reduction surgery if you meet there criteria. With Blue Cross/Blue Shield, the policies will differ from state to state as well. My suggestion would be to make an appointment with a board certified plastic surgery for a consultation and have a pre-certification initiated to your insurance to determine medical neccessity.

Patricia Yugueros, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 7 reviews

Insurance coverage

+1
Most insurance companies do cover breast reduction surgery if prior approval is submitted and you meet their criteria.  Some do require 3-6 months of conservative treatment, like physical therapy, for neck and back pain. Most do require that a certain amount of breast tissue be removed from each breast.  Your plastic surgeon can discuss this with you and determine if you might qualify with your insurance carrier.

Connie Hiers, MD
San Antonio Plastic Surgeon
5.0 out of 5 stars 4 reviews

BCBS Insurance will cover breast reduction surgery

+1
Yes, Blue Cross Blue Shield insurance will cover breast reduction if you meet certain criteria.  Individual policies will vary from state to state.  Generally, the removal of 500 grams of tissue is required per breast.  Fortunately, for small women like you, the Schnur Sliding Scale was developed.  With the Schnur Scale, your body surface area will be used to calculate how much tissue is required for insurance to consider the procedure medically necessary.  

I would recommend you obtain a consultation from a board certified plastic surgeon.  He or she will be able to send your information to your insurance company for preapproval.  If certain conditions are met, the surgery will be approved for insurance coverage.

In Alabama the BCBS policy is as follows (copied from the BCBS website):

"Reduction mammaplasty meets Blue Cross and Blue Shield of Alabama’s medical criteria for
coverage for women aged 18 or older or for adolescents whose breasts are fully developed; i.e.,
patient has maintained current height, weight, and breast size for 12 months, when:
  • a minimum of 500 grams of breast tissue is to be removed from each breast; OR 
  • a combined minimum total of 1000 grams of breast tissue is to be removed from both breasts (effective 10/01/2012); OR 
  • a women is of small stature (5 feet 3 inches and under), consideration will be given for removal of less than 500 grams of breast tissue from each breast using the Schnur Sliding Scale chart. Body surface area is calculated and then the Schnur Sliding Scale chart is used to determine the number of grams to be removed from each breast.  
And two or more of the following medical indications are met: 

  • Pain in the upper back and shoulders resulting in documented treatment and interference with activities of daily living. This pain should be evaluated to determine that it is not associated with another diagnosis such as arthritis. The pain is not relieved by conservative therapy including an appropriate support bra, exercises, heat/cold treatments and appropriate non-steroidal anti-inflammatory agents/muscle relaxants. 
  • Dermatitis of skin of shoulder or shoulder grooving not responding to conservative treatment, including support bra. 
  • Intertrigo between the pendulous breast and the chest wall 
  • Sternal notch to nipple measurements of 26 cm or greater"
(Obtained from BCBS of AL Reduction Mammaplasty Policy #056, November 2013)

Trey Aquadro, M.D.
Auburn, AL

Ralph Trey Aquadro, MD
Auburn Plastic Surgeon
5.0 out of 5 stars 7 reviews

BCBS covering Breast Reduction

+1
Many women who ask this question expect insurance breast reduction to be inexpensive and cosmetic reduction to be expensive.  As insurance changes, however, and asks more and more of the customer, the costs may be dramatically closer than you think. When a person has an operation in the hospital there are bills from the hospital, anesthesiologists, for supplies and medications, for perioperative care and for the surgeon.  When these are added up, they can become thousands very quickly. If you are considering reduction find a trustworthy and reputable surgeon who takes your insurance. While there, ask what the cost for a reduction would be out of pocket. It is not uncommon that the cost for the two is close. Unfortunately, most people don't find out the end cost until the bills come from the hospital weeks after the surgery.
Additionally, when a surgeon is doing a reduction for insurance, he or she is expected to remove certain amounts of tissue regardless of whether or not it will make your breasts look great or match your body. That is not the case with cosmetic reductions and the end results can improve as a result.
Best,
Dr. Pyle

Jeremy Pyle, MD
Raleigh-Durham Plastic Surgeon
5.0 out of 5 stars 23 reviews

Will BC/Bs cover breast reduction

+1

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.

Rick Rosen, MD
Norwalk Plastic Surgeon
5.0 out of 5 stars 8 reviews

Insurance Coverage by BCBS

+1

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.  

Norman M. Rowe, MD
New York Plastic Surgeon
5.0 out of 5 stars 17 reviews

BCBS coverage

+1

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.

Best wishes,

Dr. Basu

Houston, TX

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 117 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.