Will Blue Cross Blue Shield Cover Breast Reduction?

Great question! BCBS will require a letter of medical necessity sent on your behalf to them in order to get "pre-authorization" for the procedure. This will include information including your height, weight, symptoms (i.e. neck/back/shoulder pain) as well as shoulder strap grooving among other symptoms. Pictures are also sent. The pre-authorization process usually takes a few weeks and BCBS is quite fair in their pre-authorization approval rate. I recommend you visit a plastic surgeon in your area with experience in breast reduction who can get you on the right track. Best of luck!

The best advice I can give you is that documentation is key when it comes to trying to get insurance companies (independent of carrier) to cover a breast reduction surgery.  Each insurance carrier has set forth a set of criteria and guidelines, which can be found online and must be met, for a case to even be evaluated for medical necessity.  Most insurance companies like to see photographs and documentation from specialists and physicians across various medical specialties (including plastic surgeons, internists, orthopedic surgeons, chiropractors, physical therapists and dermatologists) attesting to the severity and length of the problem and what they have tried in the past to alleviate the issue or hardship prior to a patient's turn to plastic surgery.  Symptoms that these guidelines cover include neck, shoulder and back pain, shoulder grooving, failed physical therapy or minimal improvement, intertrigo, etc...I would recommend consulting with a board-certified plastic surgeon who will conduct a physical examination and document the necessity and that you are a good candidate for a breast reduction procedure.  Their office should also gather all necessary supporting documentation and submit to your insurance company for any pre-certification or pre-approval. It takes roughly 4-6 weeks to hear back from most carriers, so be patient and remain hopeful.  I hope this helps!

Most insurance companies have seen the wisdom of large outcome studies that show that breast works to decrease or eliminate the symptoms of large breasts.  Back pain, neck pain, shoulder grooving. See your plastic surgeon for an evaluation to see if you meet the criteria on your Blue Cross plan. Most plans require documentation of symptoms, measurements and photos, then require a certain number grams of tissue resected based on your height and weight. (Schnurr formula is used by many).  Bottom Line:  High likelihood that you can get coverage!   But unfortunately, a few plans exclude breast reduction and a few have conditions which squeeze some marginal cases out.  If if you find out that you are not covered, most plastic surgeons offer for a 'cash' price, and it is still worth doing! 

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!

Thanks for your question!  Every insurance company has their own set of criteria.  I would talk with your PCP to see if they believe it would be covered.  If so, they can refer you to a qualified plastic surgeon in your area for treatment.  Good luck!

Here are the guidelines per blue cross:
BCBS TX
Reduction Mammaplasty for symptomatic breast hypertrophy or hypermastia may be consideredallowable for coverage when there is supporting medical documentation and ALL of the medicalcriteria are met: Records documenting the patient’s significant symptoms that interfere with activities of dailyliving, including but not limited to, the following –• Pain in the upper back, neck, and shoulders which is long-standing duration andincreasing in intensity and is not related to other musculoskeletal causes (e.g., poorposture, acute strains, post traumatic conditions, poor lifting techniques, or other evidenceof over use), AND/OR• Persistent, clinical, non-seasonal sub mammary intertrigo, which is refractory andunresponsive to comprehensive local hygiene and topical anti-infective therapy, AND/OR• Ulnar nerve paresthesia or compression, which results in pain and/or numbness in thearms and/or hands. The patient’s physical exam that documents the following –• Significant shoulder grooving or ulceration of the skin of the shoulder, AND• Obvious breast hypertrophy, AND• Physical exam consistent with symptoms precipitating request for reductionMammaplasty.
Documentation of tried and failed comprehensive conservative measures including –
• A minimum of six (6) weeks of physical therapy for back, neck or shoulder pain including amaintenance home exercise program, AND• Appropriate support bra with weight distributing straps, AND• Anti-inflammatory agents unless medically contraindicated, AND• Symptomatic measures, including application of heat and cold, AND• Appropriate local hygiene and topical pharmacologic treatments for intertrigo. Documentation of patient’s body surface area (BSA), based on the Schnur Sliding Scale(SSS), in which the patient’s breast weight (per breast) is estimated at greater than the 22ndpercentile line (Refer to SSS and calculation of BSA at the end of the Rationale Section)consisting of breast tissue, not fatty tissue to be removed. 
Body Surface Area
(meters squared) :  Minimum weight of tissue to be 
removed per breast (grams)
1.35         :           199
1.40         :           218
1.45         :           238
1.50         :           260
1.55         :           284
1.60         :           310
1.65         :           338
1.70         :           370
1.75         :           404
1.80         :           441
1.85         :           482
1.90         :           527
1.95         :           575
2.00         :           628
2.05         :           687
2.10         :           750
2.15         :           819
2.20         :           895
2.25         :           978
2.30 or greater    :   >= 1000

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).

Based on the description of your symptoms and your dimensions I believe you would be a great candidate for breast reduction and likely would get approved

Breast reduction surgery can often be covered by insurance. For most insurances, there is a need to document that you have been having either back and neck pain or problems with skin hygiene under the breasts. You will need to show that a medical professional has evaluated and treated you for the issues. You will also need to have enough breast tissue to remove based on your height and weight. You can find additional links to BCBS requirements below.