Does Blue Cross Blue Shield Cover Breast Reduction Surgery?

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The Anthem family of companies – which includes Anthem Blue Cross Blue Shield – provides health coverage to 45 million people across the U.S.¹ If you need a breast reduction for medical or cosmetic reasons, you may be wondering if an Anthem Blue Cross Blue Shield Medicare Advantage (Medicare Part C) 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.

Does Blue Cross Blue Shield Medicare Cover Breast Reduction Surgery?

Whether your Blue Cross Blue Shield Medicare plan covers breast reduction surgery depends on your policy and the medical reasons why you need the surgery. Some Blue Cross Blue Shield policies may cover medically necessary breast reduction procedures if you meet the eligibility criteria.

Generally, some Anthem 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 pain symptoms and/or spinal issues associated with having disproportionately large breasts
• As part of gender-affirming treatment

While Original Medicare (Part A and Part B) typically covers breast prostheses after a mastectomy, it only covers breast reduction surgery if certain medical criteria are met. You must have significant symptoms that interfere with normal activities (such as bathing, dressing and eating) for at least 6 months, despite efforts to manage the symptoms.

The symptoms and efforts to manage them must also meet one of the following criteria:

• Your symptoms are related to back and/or shoulder pain that haven't been relieved by things like compression, massage, pain medication, physical therapy, a back brace, etc.
  
  
• Your symptoms are related to significant arthritic changes in your spine (cervical or upper thoracic), such as ulnar parasthesias, cervicalgia, torticollis or acquired kyphosis.

Your doctor must also be able to document evidence that appropriate supporting garments are causing shoulder grooving and skin irritation, or there must be signs of skin breakdown, bleeding, chronic moisture or other medical issues. Your doctor will also have to pay special attention to the amount of breast tissue removed in the procedure.

Anthem Blue Cross Blue Shield Medicare Advantage plans are required to cover everything Medicare Part A and Part B cover. Plans can also offer additional benefits, which may include breast reduction surgery in situations that Original Medicare wouldn't typically cover it.

You should always check with your plan carrier directly and talk to your doctor about your Medicare coverage before you get any procedure.

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.