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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 (28)

BCBS Insurance will cover breast reduction surgery

+2
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

Montgomery Plastic Surgeon

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 14 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.

Kansas City Plastic Surgeon
5.0 out of 5 stars 6 reviews

Reduction mammoplasty (breast reduction)

+2

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.

Chicago Plastic Surgeon
5.0 out of 5 stars 39 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
Raleigh-Durham Plastic Surgeon
5.0 out of 5 stars 10 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.

Web reference: http://www.drrickrosen.com/breast-augmentation-connecticut/

Norwalk Plastic Surgeon
5.0 out of 5 stars 7 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.  

New York Plastic Surgeon
5.0 out of 5 stars 16 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

Houston Plastic Surgeon
4.5 out of 5 stars 101 reviews

Blue Cross/Blue Shield Policies Vary From State to State

+1

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.

Omaha Plastic Surgeon
4.5 out of 5 stars 36 reviews

Blue Cross Blue Shield Coverage for Breast Reduction Varies from State to State

+1

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.

Omaha Plastic Surgeon
5.0 out of 5 stars 55 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.

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