Do Insurance Companies Cover Breast Reductions?
The short answer to this question is yes, although certain criteria must be met depending on the insurance company. Some insurance plans have specific "plan exclusions," where breast reduction surgery is not covered in any case.
In Los Angeles, breast reduction insurance coverage may vary between insurance companies. In general, the three criteria that the insurance companies look at are:
1) Symptoms must be attributable to large breasts
2) Conservative symptom management must have been tried and failed
3) A certain amount of tissue is planned to be removed based on body surface area. One example of a body surface calculator is: www.medcalc.com/body.html
Patients with excessively large breasts (macromastia) typically experience upper neck/back/shoulder pain as well as rashes under the breasts. In patients who have existing cervical spine disease, additional testing may be necessary to ensure that these symptoms are due to macromastia rather than other causes.
Conservative management of upper neck/back/shoulder pain usually consists of any non-operative treatment. This may include pain medicines, acupuncture, exercise, going to a chiropractor, physical therapy, etc. for a certain time frame, usually 3 months or so. Conservative management of rashes under the breasts may include baby powder, diaper rash ointment, or other medicated creams such as steroid ointment.
Finally, insurance companies typically ask plastic surgeons to estimate the amount of weight of breast tissue to be removed during the breast reduction surgery. In order to make this estimation, your body surface area is calculated based on your height and weight, and then this is compared to a Schnur Scale which gives an estimation of the amount of tissue necessary to be removed in order to provide symptom relief. Although multiple research studies have failed to find associations between the amount of tissue removed and symptom relief, this is nevertheless a criteria used by insurance companies.
To review specific coverage criteria by insurance company, click on the links below:
United Healthcare Breast Reduction Coverage
Anthem Blue Cross Breast Reduction Coverage
Aetna Breast Reduction Coverage
Cigna Breast Reduction Coverage
Blue Shield of California Breast Reduction Coverage