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!

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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.


Kansas City Plastic Surgeon
5.0 out of 5 stars 10 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 6 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 6 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 7 reviews

Probably

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

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

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

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

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
Chevy Chase 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.