Does Blue Cross Blue Shield Cover Breast Reduction Surgery?
- Some Anthem Blue Cross Blue Shield Medicare Advantage plans may help cover breast reduction surgery. Learn more about Medicare breast reduction coverage.
The Anthem and Blue Cross and Blue Shield families of companies – which includes Anthem Blue Cross and Blue Shield – provide Medicare Advantage (Medicare Part C) coverage to millions of Americans with Medicare. In some cases, a qualified breast reduction surgery may be covered by a Medicare Advantage plan like those offered by Blue Cross and Blue Shield.
Breast reduction surgery is a type of mammoplasty. It involves removing tissue from the breasts, and some private insurers may 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. If Original Medicare (Medicare Parts A and B) would cover your breast reduction surgery, typically a Medicare Advantage plan would be required to offer at least the same coverage.
Some Blue Cross Blue Shield policies may cover medically necessary breast reduction procedures if you meet the eligibility criteria for Original Medicare mammoplasty coverage, though you may be required to get prior approval.
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
Original Medicare typically covers breast prostheses after a mastectomy.
To qualify for coverage, you typically 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 additional pain management and treatment options that Original Medicare doesn't cover, such as prescription drugs.
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?
All healthcare insurance policies that cover a 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.
A Medicare Advantage plan from Blue Cross Blue Shield may cover breast reduction surgery if your policy covered your mastectomy and you require surgery to make your breasts symmetrical. However, plans likely won't cover reconstructive surgery if you had a mastectomy for reasons not deemed medically necessary.
What Are the Blue Cross Blue Shield Breast Reduction Weight Requirements?
Your eligibility for Medicare 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.
Some Blue Cross Blue Shield plans may 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.
Blue Cross Blue Shield Breast Reduction Exclusions
Blue Cross Blue Shield Medicare Advantage plans likely won't 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.
How Much Does Breast Reduction Surgery Cost With Insurance?
How much a breast reduction procedure costs with Blue Cross Blue Shield healthcare insurance depends on your plan. If you qualify for coverage, you may need to pay certain deductibles, copays or coinsurance, and you may need to seek care from a provider who is part of your Blue Cross and Blue Shield plan network.
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