Do Insurance Companies Cover Breast Reductions?

The short answer is yes. Breast reduction surgery may be covered by insurance when specific criteria are met. Coverage varies by insurance company and your individual plan, and some plans have plan exclusions where breast reduction is not covered under any circumstance.

Los Angeles board-certified plastic surgeon Dr. Elliot Hirsch performs breast reduction surgery for patients from Los Angeles, Sherman Oaks, and throughout California, as well as nationally and internationally.

Many insurance companies evaluate breast reduction as a “functional” procedure (medical necessity), meaning physical symptoms related to large breasts (macromastia) must be documented.

In general, the three criteria insurance companies look at include:

1. Symptoms must be attributable to large breasts (macromastia)
2. Conservative (non-surgical) symptom management such as physical therapy or accupuncture must have been tried for a certain amount of time and failed
3. A minimum amount of breast tissue is planned to be removed based on body surface area (often using the Schnur Scale)

What insurance companies typically require for breast reduction coverage

1) Symptoms that may support medical necessity

Patients with excessively large breasts (macromastia) commonly report:

• Upper back, neck, or shoulder pain
• Shoulder grooves from bra straps
• Rashes or skin irritation beneath the breasts
• Limitations with exercise or physical activity

For patients with existing cervical spine disease or other conditions, additional testing may be recommended to confirm symptoms are primarily related to macromastia.

2) Conservative treatment documentation

Insurance companies often require documentation showing that non-surgical treatments were tried before surgery was recommended. Examples may include:

• Physical therapy, home exercise programs, or activity modification
• Anti-inflammatory or pain medications (as appropriate)
• Chiropractic care or acupuncture
• Supportive bras or other conservative measures

Conservative treatment for rashes beneath the breasts may include baby powder, barrier creams (such as diaper rash ointment), or medicated creams (including steroid ointments when appropriate).

3) Estimated tissue removal and the Schnur Scale

Insurance companies typically request an estimate of how much breast tissue will be removed. This estimate is often based on your body surface area (calculated using height and weight) and compared to the Schnur Scale.

Although research has not consistently shown that symptom relief is strictly tied to a specific tissue amount removed, the Schnur Scale is still commonly used as part of insurance criteria.

Review specific coverage by insurance company:

• 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

To learn more about breast reduction, visit:

• Breast Reduction Page
• American Society of Plastic Surgeons Breast Reduction Page (opens in a new tab)

Frequently Asked Questions
Breast Reduction Insurance Coverage

How can I find out if my insurance plan covers breast reduction surgery?

The best way to find out if your PPO plan covers breast reduction surgery is to call the number on the back of your insurance card and ask if breast reduction surgery is a covered benefit. If it is a covered benefit, then the authorization process is similar to every other surgical procedure.
 

What do I do if my insurance does not cover breast reduction surgery?

If your PPO plan does not include breast reduction surgery as a covered benefit, you can consider paying out of pocket for the procedure or even changing insurance plans. Dr. Hirsch and his team will discuss options with you at your consultation.

To schedule a consult with Dr. Hirsch, please call the office at 818-825-8131 or fill out our contact form.
 

How much does a breast reduction cost if it is covered by insurance?

If insurance covers your breast reduction, you are typically responsible for your in-network deductible and your in-network co-payment. Depending on the facility that is used for your surgery, Dr. Hirsch may be able to accept your insurance.
 

What is the difference between a breast lift and a breast reduction?

A breast reduction reduces the size of the breast and lifts/reshapes the breasts. A breast lift does not usually make a significant difference in size and only lifts/reshapes the breasts. A breast reduction can be covered by your PPO insurance, while a breast lift is not usually covered by insurance.