Blue Cross Blue Shield generally will cover a breast reduction if you meet their criteria.
Usually that includes, back and neck pain, rashes under the breasts, and large breasts (which are large enough). If you have the right symptoms but the breasts aren’t large enough, they may not approve the surgery.
Your surgeon will be able to tell you during your consultation if they are large enough to gain approval from BCBS. (Allen M. Doezie, MD, Orange County Plastic Surgeon)
Blue Cross/Blue Shield and some other insurance companies will cover Breast Reduction surgery if you meet there criteria.
With Blue Cross/Blue Shield, the policies will differ from state to state as well.
My suggestion would be to make an appointment with a board certified plastic surgery for a consultation and have a pre-certification initiated to your insurance to determine medical neccessity. (Patricia Yugueros, MD, Atlanta Plastic Surgeon)
BCBS covering Breast Reduction
Many women 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. (Jeremy Pyle, MD, Raleigh-Durham Plastic Surgeon)
Health insurance agencies will typically “cover” breast reduction operations if you adhere carefully and qualify based of their criteria. It may be helpful to call your health insurance provider and find out what their specific criteria may be.
Each Insurance agency differs. Oftentimes quite a bit of documentation must be provided by you and your primary care physician to help prove that you have met the insurance criteria. A consultation with a plastic surgeon can also help you find out if you are a good candidate for breast reduction and if you are likely to be able to meet Insurance criteria. (Rachel Streu, MD, Portland Plastic Surgeon)
It is difficult to say for sure whether your insurance will cover your reduction.
Insurance companies have made it more difficult to get coverage over the last 20 years by increasing the amount of tissue that needs to be removed and adding other body mass index requirements.
Also every insurance policy is different and some do not cover breast reductions at all.
Best to see an experienced Plastic Surgeon and they can help you find out if your surgery might be covered. (G. Wesley Price, MD, Chevy Chase Plastic Surgeon)
It is not possible to guarantee insurance coverage for breast reduction, but there are several factors that insurance companies typically use to evaluate reimbursement for breast reduction surgery: history of breast pain, neck-, back-, shoulder-pain, that haven’t been relieved by medication, exercise, physical therapy; pain with exercise or interference with exercise; recommendation for breast reduction and documentaion by physical therapist, primary care doctor, orthopedic surgeon or neurosurgeon; the amount of breast tissue removed at surgery.
Be sure to check with your insurance company and submit documentation before surgery. (Paul C. Zwiebel, MD, Denver Plastic Surgeon)
All insurance companies are in business to make money. They do that by taking in more money than they spend on covering their insured population. If they can deny coverage they make more money. They used to publish what was required weight wise for a breast reduction t be covered.
These days they don’t tell the doctor or the patient. It is that possibility of you having to pay for your surgery that discourgage you from proceeding and is what they count on to make money.
You can try to get precertified for the procedure based on symptoms. Remember, the squeaky wheel gets greased.
Keep after them and don’t give up until you get the answers you deserve about why or why not they will cover your procedure. (A. Dean Jabs, MD, PhD, FACS, Bethesda Plastic Surgeon)
Insurance coverage of breast reduction surgery
It is difficult to predict without more information whether your insurance company will cover the surgery. Every insurance company has different requirements, and some companies will pre-authorize surgery while others will not. In general, the insurance companies will want to know if you have back pain, neck pain, shoulder pain, shoulder grooving, and if you get rashes underneath your breasts.
They want to know if you have tried other things to alleviate your symptoms. At the end of the day, one of the main things they care about is how much breast tissue is removed from each breast.
They sometimes use complicated formulas to come up with a weight that must be removed in order for the procedure to be covered. You can call your insurance company and ask about their specific requirements. (Samir S. Rao, MD, Chevy Chase Plastic Surgeon)
Will insurance cover my breast reduction?
Insurance requirements vary from plan to plan and also within plan subtypes. The only way to know is to be evaluated by a plastic surgeon. If you are found to be a candidate for the surgery, a pre-authorization is submitted to the insurance to see if they “approve” it or not.
Approval depends on the plan and it’s requirements AND on whether or not they find it to be “medically necessary”. Note that even if they approve it based on medical necessity, there is always a chance that they will deny it later since they state that “approval is not a guarantee of payment”.
That being said, there are definitely factors that affect medical necessity. For example, if you answer yes to multiple of the following questions, there is a good chance that a good insurance plan will cover it, particularly when there are months of medical documentation to support it:
- Have been to a doctor in the past 2 years to discuss pain due to large breasts and neck/shoulder/back pain?
- Have you ever had an infection or rash under you breasts for which you have been to the doctor?
- Have you ever been sent to physical therapy or a chiropractor?
- Do you take medications often for the pain?
- Have you ever had xrays or an MRI of the neck or back? (Orna Fisher, MD, Palo Alto Plastic Surgeon)
Insurance coverage of breast reduction varies by company
Each company has different requirements for covering breast reduction. But they all look at similar factors. Do you have symptoms caused by having large breasts? These include neck and back pain, grooving in your shoulders from your bra strap, breast pain, and rashes under the breasts.
Have you tried nonsurgical treatment for these symptoms? This may include over-the-counter or prescription pain medication, seeing a chiropracter, physical therapy, wearing a sports bra, using ice or hot packs, and using topical creams for any rashes.
Have other causes of these symptoms been ruled out? Your primary care doctor can assess this for you. Will enough tissue be removed?
Every insurance company has a different minimum number, and it varies by your height and weight as well.
Your plastic surgeon will estimate this number during your consultation. A quick call to your insurance company can help you find their specific requirements. (Jennifer Greer, MD, Cleveland Plastic Surgeon)
Every insurance plan has different requirements, even within BC/BS. The only way to find out is to have a board certified plastic surgeon write a letter of preauthorization to the insurance company and have them check your individual policy. (Gary Lawton, MD, FACS, San Antonio Plastic Surgeon)
Most insurance companies do cover breast reduction surgery if prior approval is submitted and you meet their criteria. Some do require 3-6 months of conservative treatment, like physical therapy, for neck and back pain. Most do require that a certain amount of breast tissue be removed from each breast.
Your plastic surgeon can discuss this with you and determine if you might qualify with your insurance carrier. (Connie Hiers, MD, San Antonio Plastic Surgeon)
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. (Rick Rosen, MD, Norwalk Plastic Surgeon)
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. (Norman M. Rowe, MD, New York Plastic Surgeon)
Blue Cross/Blue Shield Policies Vary From State to State
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. (John J. Edney, MD, Omaha Plastic Surgeon)
Some insurance carriers still cover breast reduction procedures, a pre authorization letter will need to be submitted by your plastic surgeon to determine coverage. Blue Cross/Blue Shield is one of the better carriers. (David Finkle, MD, Omaha Plastic Surgeon)
Depending upon the specific policy, Blue Cross may cover your breast reduction. However, the precertification and benefits department must be contacted first to see if you are covered.
The insurance company coverage varies from state to state so it is best to have the coverage reviewed. (Thomas Guillot, MD, Baton Rouge Plastic Surgeon)
Breast Reduction and Insurance
In some cases, insurance will pay for part or all of a woman’s breast reduction surgery. This typically depends on whether or not your insurance company regards the procedure as medically necessary.Your insurance company may make this decision based on how much breast tissue will be removed, and they may require you to provide documentation (via your primary care doctor and a physical therapist) that your breast size is causing you physical problems like neck, shoulder and back pain, deep bra strap grooves, and skin rashes beneath the breasts which would be resolved with surgery.
Once the need for surgery is established, you would then need to consult with a plastic surgeon for further recommendations. Even if your insurance will not cover all or any of the costs of surgery, you should still consider having a breast reduction as this would likely improve or resolve many of your physical symptoms.
It is always best to contact your insurance company directly and see what qualification need to be met in order for them to cover the procedure. From there you can take the proper steps required to try and get the procedure performed.(Robert Cohen, MD, Santa Monica Plastic Surgeon)
Breast reduction insurance coverage
Blue Cross Blue Shield does cover breast reductions but not every patient will be approved. Your plastic surgeon will meet with you and take various measurements and pictures to submit to the insurance companies along with a letter to support the case.
The insurance companies will then assess your information and decide if you are a good candidate under their guidelines. It can be a very frustrating process because some people who would really benefit from the surgery do not get approval.
I would definately meet with your physician and try for coverage. (Neil J. Zemmel, MD, FACS, Richmond Plastic Surgeon)