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

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

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.

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. 

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.

Not only does each insurance company have different policies, but each policy from the same company can be different. You will need to see a board certified plastic surgeon who can examine you and then get authorization from your insurance company. Typically it takes 4-6 weeks after submission of the information for the insurance company to decide. Good luck to you; it sounds like you could really benefit from this surgery.