Will Blue Cross Blue Shield Cover Breast Reduction?

Each insurance provider will have different requirements for approval of reduction surgery. Generally speaking, one must pre-operatively document a medical necessity for surgery and failure of more conservative options including physical therapy, medical therapy, weight loss. Post operatively, your surgeon must document adequate tissue removal (often based on Body Surface Area-BSA and the Schnur Scale).As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Each insurance plan has its own set of criteria for coverage. Insurance companies typically require clear documentation of symptomatic macromastia.
Symptomatic macromastia is a condition is often associated with symptoms such as chronic back, neck, and shoulder pain, skin irritation or rashes beneath the breasts, difficulty finding properly fitting clothing or bras, and limitations in physical activity. Women with symptomatic macromastia may also experience emotional distress due to the discomfort and the effects on their daily lives. In many cases, breast reduction surgery is considered a viable solution to alleviate these issues by removing excess tissue, reducing breast size, and improving both physical comfort and overall quality of life. Insurance may cover the procedure if it is deemed medically necessary based on the presence of these symptoms and other supporting factors.
To build a case for medical necessity, it's important to document attempts at conservative treatments such as weight loss, physical therapy, pain management, and medication for symptoms like back, neck, or shoulder pain. Many insurance plans will also require a certain amount of tissue removal, typically determined by the Schnur Scale, which evaluates factors such as body weight, body mass index, and body surface area. Your primary care provider can also document your efforts with non-surgical treatments and provide referrals when applicable.
Next, consult with a plastic surgeon specializing in breast reduction surgery. The surgeon will assess your condition and measure the amount of excess tissue, which is important for the insurance submission. Often, the surgeon will also provide supporting letters outlining your symptoms and the need for surgery. Additionally, it can be helpful to gather letters from other healthcare providers, such as physical therapists. By thoroughly documenting your case and following these steps, you can improve your chances of securing insurance approval for the procedure.
Best wishes on your journey!
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

Hello there, this is a great question. Sometimes medical insurance can cover a breast reduction, but in our office we don't accept insurance. Wish you the best of luck!