Does BCBSIL Cover Breast Reduction Surgery? (Reduction Mammaplasty for Systematic Breast Hypertrophy or Hypermastia)
Answer: Yes, if you meet their list of requirements and receive a pre-authorization. We'd recommend talking over these requirements with your doctor as they will be more familiar with the pre-auth process.
Breast Reduction - Reduction Mammaplasty for Systematic Breast Hypertrophy or
Hypermastia – NO PHOTOS
Reduction Mammoplasty for symptomatic breast hypertrophy or hypermastia may be considered allowable for coverage when there is supporting medical documentation and ALL of the medical criteria are met:
- Records documenting the patient’s significant symptoms that interfere with activities of daily living, including but not limited to, the following –
- Pain in the upper back, neck, and shoulders which is long-standing duration and
increasing in intensity and is not related to other musculoskeletal causes (e.g., poor
posture, acute strains, post traumatic conditions, poor lifting techniques, or other evidence of over use), AND/OR
- Persistent, clinical, non-seasonal sub mammary intertrigo, which is refractory and
unresponsive to comprehensive local hygiene and topical anti-infective therapy, AND/OR
- Ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and/or hands.
- The patient’s physical exam that documents the following –
• Significant shoulder grooving or ulceration of the skin of the shoulder, AND
• Obvious breast hypertrophy, AND
• Physical exam consistent with symptoms precipitating request for reduction Mammaplasty.
Documentation of tried and failed comprehensive conservative measures including –
• A minimum of six (6) weeks of physical therapy for back, neck or shoulder pain including a maintenance home exercise program, AND
• Appropriate support bra with weight distributing straps, AND
• Anti-inflammatory agents unless medically contraindicated, AND
• Symptomatic measures, including application of heat and cold, AND
• Appropriate local hygiene and topical pharmacologic treatments for intertrigo.
- Documentation of patient’s body surface area (BSA), based on the Schnur Sliding Scale (SSS), in which the patient’s breast weight (per breast) is estimated at greater than the 22nd percentile line Refer to SSS and calculation of BSA at the end of the Rationale Section) consisting of breast tissue, not fatty tissue to be removed.
Medical Policy Reference: SUR716.012