Insurances that cover breast reduction

Dealing with the physical and emotional challenges of overly large breasts is difficult enough without the added stress of figuring out whether your insurance will cover breast reduction surgery. Many major insurance companies do cover breast reduction surgery when it’s deemed medically necessary, but each insurer has specific requirements you’ll need to meet.

In this guide, we’ll walk you through some of the different insurances that cover breast reduction surgery, the types of documentation you’ll need, and how to work with your surgeon’s office to navigate the approval process.

Insurance Coverage Comparison

Note: Other providers not listed may also cover breast reduction surgery, with specific coverage guidelines varying depending on the details of your plan.

NYSHIP Empire Plan Breast Reduction Coverage

The New York State Health Insurance Program (NYSHIP) Empire Plan is one of the most common insurance plans for New York state employees, and many patients at Harris Plastic Surgery use this coverage.

NYSHIP Empire Plan Eligibility

The Empire Plan covers breast reduction when it’s medically necessary to permanently resolve chronic symptoms associated with large breast size. The Schnur Scale is used to determine whether the amount of tissue removed is considered medically necessary.

Other medical necessity criteria include:

• Chronic neck and upper back pain that hasn’t responded to conservative treatments
• Chronic skin conditions (rashes, infections) under the breasts 
• Correction of asymmetry following unilateral mastectomy (covered under federal law)

Key documentation requirements:

• Letter from your plastic surgeon explaining medical necessity
• Photographs documenting breast size and any skin conditions
• Detailed history (min. 6 months) of symptoms and how they impact your quality of life
• Records from other healthcare providers (physical therapists, chiropractors, primary care physicians) supporting the need for surgery
• Documentation from a physician that you have tried conservative treatments 

Cigna Breast Reduction Coverage

Cigna provides specific guidelines emphasizing medical necessity based on symptoms and tissue removal requirements.

Cigna’s Medical Necessity Requirements

Cigna covers breast reduction for women 18+ (or with completed breast growth) when all criteria are met:

Symptomatic macromastia causing at least one condition unresponsive to medical management:

• Shoulder, upper back/neck pain, and/or ulnar nerve palsy with no other identified cause
• Intertrigo, dermatitis, eczema, or hidradenitis at the inframammary fold

AND photographic documentation confirming:

• Significant breast hypertrophy
• Shoulder grooving from bra straps (if present)
• Visible skin conditions (if present)

Tissue removal requirements: 

Average grams removed per breast must be above the 22nd percentile on the Schnur Sliding Scale based on your body surface area (BSA), or more than 1 kilogram per breast, regardless of BSA.

What Cigna Won’t Cover

• Surgery solely for psychological symptoms 
• Psychosocial complaints without significant physical findings
• Surgery only to improve appearance
• Liposuction as the sole treatment method

Anthem Breast Reduction Coverage

Anthem provides clear medical necessity criteria for breast reduction coverage, using a straightforward approach based on symptoms and tissue removal.

Anthem’s Medical Necessity Criteria

Anthem considers breast reduction medically necessary when you meet specific requirements. You must have one or more of the following conditions:

Qualifying conditions:

• Upper back/shoulder pain that interferes with daily activities or work, clearly related to breast weight, with at least 3 months of conservative treatment including support garments, NSAIDs, physical therapy, or similar modalities
• Submammary intertrigo (rash/infection under breasts) refractory to conventional medications, or shoulder grooving with ulceration unresponsive to conventional therapy
• Thoracic outlet syndrome (including ulnar paresthesias from breast size) that hasn’t responded to at least 3 months of adequate conservative treatment

AND one of the following tissue removal criteria:

• Option 1: An Appropriate amount of breast tissue will be removed from at least one breast based on your BSA using the Schnur Sliding Scale. 
• Option 2: Regardless of BSA, if at least 1 kilogram of tissue will be removed from each breast, the surgery is considered medically necessary when you have qualifying symptoms.

What Anthem Requires for Pre-Authorization

Anthem needs comprehensive documentation, including:

• Height and weight for BSA calculation
• Description of breast size and shape causing symptoms
• Estimated tissue removal amount per breast
• Clinical photographs (may be requested)
• Medical records from your primary care physician and other providers (physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated your symptoms

What Anthem Won’t Cover

Anthem explicitly excludes coverage for:

• Poor posture alone (without other qualifying conditions)
• Breast asymmetry
• Pendulousness (drooping breasts)
• Problems with clothes fitting
• Nipple-areola distortion
• Breast cancer risk reduction
• Liposuction as the sole method of breast reduction

Medicare Breast Reduction Coverage

Medicare covers breast reduction surgery under specific circumstances, though the criteria differ slightly from those of private insurance companies.

Medicare’s Coverage Criteria

Medicare considers breast reduction medically necessary when you have significant symptoms that have interfered with normal daily activities despite conservative management for at least six months, including at least one of the following:

• Chronic back and/or shoulder pain affecting activities of daily living, unrelieved by conservative treatments 
• Significant arthritic changes in the cervical or upper thoracic spine with persistent symptoms despite optimal management
• Signs and symptoms of ulnar paresthesias (numbness/tingling in the forearms), neck pain, or acquired kyphosis (a spinal condition causing a “hunch-back” appearance) 
• Intertriginous maceration (rash) or infection of the skin under the breasts that doesn’t respond to topical ointments
• Shoulder grooving with skin irritation from bra straps

Medicare uses body surface area (BSA) to establish guidelines for tissue removal. These are guidelines, not absolute rules, and the amount of tissue removed should be appropriate to relieve your symptoms.

Important Medicare Limitations

• Medicare does not cover cosmetic surgery to reshape breasts for appearance
• The procedure must be performed to improve function and relieve symptoms

What to Expect for Out-of-Pocket Costs

Even with insurance coverage, it’s important to be prepared for some out-of-pocket costs. Many patients are still required to pay:

• Deductible: The annual amount you pay before your insurance coverage begins (typically a few hundred to several thousand dollars)
• Co-pays: Flat amounts per doctor visit (typically $20-50)
• Coinsurance: A percentage of covered costs you pay after your deductible is met (usually 10-20%)

Additional possible expenses include: 

• Anesthesia fees (sometimes billed separately)
• Post-surgical compression garments
• Prescription medications
• Follow-up visit costs
• Pre-operative testing

Working with Out-of-Network Providers

Even if your preferred surgeon is out-of-network, you may still access coverage. At Harris Plastic Surgery, we regularly assist patients in negotiating coverage with the NYSHIP Empire Plan and many other insurance providers for out-of-network care, giving you flexibility to choose a surgeon you’re comfortable with rather than having your insurance provider dictate your options.

For breast reduction surgery, having your choice of plastic surgeon is particularly valuable. It allows you to select someone with extensive experience in the specific technique you’re interested in, or a surgeon whose approach aligns with your medical needs and goals.

How to Maximize Out-of-Network Benefits

To make sure you’re utilizing your coverage properly, review your plan’s Explanation of Benefits (EOB). Look for details about:

• Out-of-network coverage percentages
• Out-of-network deductibles (often higher than in-network)
• Out-of-network out-of-pocket maximums
• Any caps on allowable charges
• Reimbursement rates

Many plans cover 50-70% of out-of-network procedures once you’ve met your deductible, which can result in significant savings.

The No Surprises Act: Critical Protections for Out-of-Network Care

Even if you choose an out-of-network plastic surgeon for your breast reduction, the No Surprises Act protects you from surprise bills from certain ancillary providers involved in your care when the surgery takes place at an in-network facility, including:

• Anesthesiologists
• Assistant surgeons
• Pathologists 
• Laboratory services 
• Radiologists

This means even if you select an out-of-network surgeon for your expertise and preference, you won’t face surprise bills from other providers involved in your surgery, provided your surgery takes place at an in-network hospital or ambulatory surgical center.

Maximize Your Benefits with Harris Plastic Surgery

At Harris Plastic Surgery, we’re committed to helping you get deserved coverage, whether you’re in-network or out-of-network. Dr. Stephen Harris brings decades of breast reduction surgery expertise, and our patient care team, led by Joanne Parrinello, specializes in navigating even complex insurance situations, including out-of-network benefits and No Surprises Act protections.