Will Blue Shield of California cover my breast reduction? What are their requirements?

Thank you for the question. Based on your description, you may be a good candidate for breast reduction surgery at some point; best to achieve your long-term stable weight prior to proceeding. “Official” recommendations of course would necessitate in-person consultation.Breast reduction surgery is one of the most patient pleasing operations we perform. By removing “excess” breast tissue, adipose tissue, and breast skin  this operation reduces AND lifts the breasts to a higher position on the chest wall (in other words, the breasts are "automatically" lifted when a breast reduction is performed). By doing so, patients often find improvement in neck, back, and shoulder discomfort and find it easier to form their activities of daily living and exercise.Timing of the operation will depend on the patient's life circumstances. Sometimes breast  reduction surgery is covered through health insurance. The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.When the time is right,  seek consultation with well-trained/experienced board-certified plastic surgeons. Ask to see lots of examples of their work and communicate your goals clearly. Best NOT  to communicate your goals in terms of achieving a specific cup size; this type of communication can be a source of miscommunication. In my practice, I prefer the use of goal pictures during this communication phase;  many patients wish to remove enough breast tissue to improve/alleviate symptoms while maintaining upper/lower body proportionality.I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps.

The answer to this question is pretty astounding, after spending about an hour trying to get an answer for you and all the other plastic surgeons in California I was told the following: "Prior authorization for breast reduction is not required". CPT 19318 Reduction mammaplasty "just gets paid". As you know, many insurance companies require very detailed documentation of height, weight, body surface area, amount of grams of breast tissue estimated to be removed, six months or more of documented symptoms such as neck, back, and shoulder pain, bra-strap grooving, possible neurologic symptoms such as tingling in the ulnar nerve distribution, intertrigo (rashes under the breast), medical records from all treating physicians, a mammogram for patients 40 and older. You could do a Google search under "Blue Shield of California breast reduction guidelines" and find links to Blue Shield of Minnesota, or Empire Blue Shield with multiple page documents asking for all of these criteria.So when I was told that Blue Shield of California does not require prior authorization I was concerned that there could be an unpleasant surprise when the bill was submitted.  To get this in writing, I was told that a "two-step process" could be undertaken.First: Write on letterhead to Blue Shield requesting authorization for breast reduction. You will get a reply from Blue Shield saying "authorization is not required". Second:  Send in all the usual documentation that you would use for other insurance companies and ask for a "Courtesy Review".  You will then receive in writing a statement for your particular patient that prior authorization is not required.To answer your question, then. Just go to an experienced board-certified plastic surgeon, have your consultation in the usual manner and have their office process the paperwork.  If one were to believe what I was just told by the authorization department, Amy P, who had the question answered by a "lead" who is an RN who reviews these requests, you could just have the procedure and not bother with the paperwork. Providers can go to the Blue Shield provider website and search under Reduction Mammaplasty and will see that the breast reduction policy was retired in February, 2012

Inssurance coverage for breast reduction requires a doctor visit, consult and submission of documentation. Documentation of functional issues like neck pain, shoulder strapping etc... Is usually enough.