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 (37)

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 18 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 7 reviews

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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
4.5 out of 5 stars 3 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.

Jerome Edelstein, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 74 reviews

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.

Gary Lawton, MD, FACS
San Antonio Plastic Surgeon
5.0 out of 5 stars 23 reviews

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

Insurance covering Breast Reduction

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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.

David Liland, MD
Dallas Plastic Surgeon
4.5 out of 5 stars 13 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 51 reviews

Will insurance cover Breast Reduction Surgery?

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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

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.