How to get insurance to cover breast reduction Blue Cross Blue Shield

I recently saw a female college student as a new patient consultation in my office concerning possible breast reduction surgery. This procedure, also known as reduction mammaplasty, is indicated for the treatment of symptomatic macromastia (large breasts). The commonly reported symptoms related to macromastia are neck, shoulder and back pain caused by the weight of overly large breasts upon the musculoskeletal system. Other secondary symptoms can include breast pain and dermatitis or rashes beneath the breasts.

The college student was referred to me by her gynecologist and arrived with a prescription recommending a consultation with a plastic surgeon due to her condition. The patient was under the common impression that because she was referred to me by another physician, that the suggested surgery would automatically be covered by her health insurance plan. She came in hoping that the breast reduction surgery could be scheduled in four weeks, during her winter break from college.

After completing a patient history and regional breast examination, my staff discussed with her what would be needed to obtain insurance authorization for her surgery.

As it turned out, this patient had no other medical treatment or previous consultations concerning her macromastia. She also had no history of being referred for physical therapy, chiropractic treatment, an orthopedic consultation or a dermatology exam. For many procedures, this lack of treatment history might not be an issue. But for breast reduction, which can be considered cosmetic or reconstructive, depending on the patient – and the insurance company reviewer – the lack of history for this patient would prove problematic.

Unfortunately, the patient had not completed all of the regimens that her insurance required for the reduction procedure to be covered in her case. She will be able to reapply for reduction mammoplasty coverage after the requirements have been completed, but, unfortunately, there is still no guarantee that her insurance will cover the procedure. Naturally, as a college student, she was not in the position to consider paying out-of-pocket for the procedure and was not happy to discover the insurance hurdles she would need to go through for potential coverage.

This story is just an example of why it's so important for patients to do their homework regarding their insurance coverage for any surgical procedure before seeing a surgeon. The answer to "is breast reduction surgery covered by health insurance?" can be very complicated and involve many variables.

Breast reduction and health insurance

It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure.

In the case of breast reduction, however, for insurance purposes, it will typically be considered a cosmetic procedure until the patient can prove an adequate number of health issues and attempted remediations of those issues prior to undergoing corrective surgery. Once the threshold has been reached, the insurance company may then consider breast reduction a reconstructive procedure for that patient and cover it. The problem is that the threshold can be different for every insurance company or insurance company reviewer. It is my opinion that breast reduction surgery has long been thought of as a "hybrid" procedure. It is considered reconstructive in attempts to obtain insurance coverage for the surgery, but it is also considered cosmetic in that patients expect meticulous aesthetic expertise in their surgery and results.

In our practice, it has become increasingly difficult to obtain insurance coverage for breast reduction surgery. Insurance companies frequently require 2-3 documented reports from other referred specialists before they'll consider covering it. Also, the insurance companies commonly request 6-12 months of documentation and treatment by either a physical therapist, chiropractor, dermatologist or orthopedist.

What does this mean for a patient who needs the procedure due to chronic health problems caused by macromastia? Keep yourself updated on policies during this process, as the insurance company's criteria are this year might not be the same next year.

If you feel that you are a candidate for breast reduction surgery and are requesting coverage under your health insurance, it is important that you contact your health insurance carrier and have them forward to you in writing their criteria for coverage. Every insurance company has different, independent criteria and indications. While your neighbor down the street may qualify for the procedure via one insurance carrier with a seemingly less severe situation, you may not be given the same answer by yours. On average, it takes between 3-6 months of preparation, including secondary consultations with other healthcare providers and possible therapy (physical therapy or chiropractics) to qualify for insurance coverage for breast reduction.

How do you handle this? Notify your primary care physician as soon as possible concerning any symptoms which may be related to your macromastia. It is never too early to start the process. Please contact your plastic surgeon's office with any questions you might have that relate to breast reduction surgery and coverage through your health insurance and they can try to help guide you through the process, so that you can obtain the care you need.

• Blue Cross Blue Shield healthcare plans may cover breast reduction surgery. Find out who qualifies for Blue Cross Blue Shield breast reduction coverage.

Roughly a third of Americans have healthcare insurance through a Blue Cross Blue Shield company. If you need a breast reduction for medical or cosmetic reasons, you may be wondering if your Blue Cross Blue Shield plan will cover the costs of your surgery.

Breast reduction surgery is sometimes called reduction mammoplasty. It involves removing tissue from the breasts, and some private insurers include it as a covered benefit in certain circumstances. Below, you can learn about the Blue Cross Blue Shield breast reduction eligibility requirements.

Whether Blue Cross Blue Shield covers breast reduction surgery depends on your policy and which company you purchased it from. Some Blue Cross Blue Shield policies cover medically necessary breast reduction procedures if you meet the eligibility criteria.

Click below to shop for Blue Cross Blue Shield plans that may cover breast reduction surgery or continue reading to learn more about this coverage.

Shop for Blue Cross Blue Shield Plans

Generally, Blue Cross Blue Shield policies may cover breast reduction in the following circumstances:

• To address breast asymmetry following a medically necessary mastectomy or lumpectomy
• To reduce symptoms associated with having disproportionately large breasts
• As part of gender-affirming treatment

What Are the Blue Cross Blue Shield Breast Reduction Eligibility Requirements?

Eligibility requirements for breast reduction surgery vary across policies and providers. Generally, you must be 18 or older to be eligible. However, Blue Cross Blue Shield may cover enrollees younger than 18 whose breasts have finished growing (no growth for a minimum of 1 year) if they have consent from their parent or legal guardian.

Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Alternatively, you may qualify if your breast size causes significant symptoms, such as:

• Long-term neck, shoulder or neck pain
• Grooving where the bra straps sit on the shoulder
• Persistent skin irritation (intertrigo) around the breasts

Blue Cross Blue Shield may require you to try conservative treatment options like anti-inflammatory medications, supportive garments or physical therapy before approving coverage. 

All healthcare insurance policies that include medically necessary mastectomy are legally required to also cover reconstructive breast surgeries, per the Women's Health and Cancer Rights Act of 1998. However, there is no legal requirement for healthcare insurance plans to cover mastectomies. You'll likely be eligible for Blue Cross Blue Shield breast reduction coverage if your policy covered your mastectomy and you require surgery to make your breasts symmetrical. However, the company does not cover reconstructive surgery if you had a mastectomy for reasons not deemed medically necessary. 

Breast reduction surgery as part of a gender-affirming treatment protocol may be a covered benefit, depending on your plan. You should check your company's Transgender Services policy and your plan documentation to determine if your policy includes the procedure. 

What Are the Blue Cross Blue Shield Breast Reduction Weight Requirements?

Your eligibility for Blue Cross Blue Shield breast reduction coverage may depend on the weight of the breast tissue your surgeon intends to remove. However, you'll need to also meet the other eligibility requirements.

Many Blue Cross Blue Shield plans require beneficiaries to meet Schnur scale criteria. The Schnur scale determines the therapeutic necessity of breast reduction surgery by comparing the weight of the removed tissue to your total body area. 

Like many healthcare insurers, Blue Cross Blue Shield companies often require beneficiaries to plot on or above the 22nd percentile of the Schnur scale to be eligible. Usually, you will qualify if only one breast meets the criteria, even if your surgeon also removes tissue from the other breast to create a symmetrical appearance. 

Blue Cross Blue Shield Breast Reduction Exclusions

Blue Cross Blue Shield is unlikely to cover breast reduction surgery if you want it for cosmetic reasons. For example, your policy will likely exclude coverage of surgery to improve the appearance of your breasts.

Generally, you must exhibit physical, objective symptoms to qualify. Therefore, you're unlikely to be eligible if your breast size causes you to experience psychological or psychosocial distress but no physical discomfort. 

How Much Does Breast Reduction Surgery Cost With Insurance?

According to the American Society of Plastic Surgeons, you should expect to pay around $5,913 for breast reduction surgery without insurance. However, the actual costs could be considerably higher, as this price doesn't account for extra services like anesthesia. 

How much a breast reduction procedure costs with Blue Cross Blue Shield healthcare insurance depends on your plan. If you qualify for coverage, the insurer will cover most of the costs of your treatment, minus any copayments and deductibles.