Insurance Guide
Anthem Blue Cross and Blue Shield, formerly Empire BlueCross BlueShield in New York, often covers breast reduction and lift for patients with symptomatic macromastia, meaning large, heavy breasts that cause physical discomfort.
This guide explains Anthem’s medical necessity requirements for breast reduction, how much breast tissue may need to be removed, and how we handle insurance preauthorization for breast reduction and lift at Kiwanuka Plastic Surgery in New York City.
Summarized from Anthem Clinical UM Guideline CG-SURG-71, last reviewed May 14, 2026. Insurer policies change, and your plan documents control.
Anthem, which now operates Empire BlueCross BlueShield, publishes its criteria in Clinical UM Guideline CG-SURG-71, Reduction Mammaplasty. Breast reduction is considered medically necessary when the following are documented.
Anthem may also request photographs and records from your other doctors. The guideline does not list a mammogram requirement.
Anthem uses the Schnur scale, a chart that pairs your body surface area, calculated from height and weight, with a reference amount of tissue removed per breast. The planned removal from at least one breast must be above the 22nd percentile for your size.
Minimum tissue removal per breast at the 22nd percentile of the Schnur scale. Our team checks your measurements against Anthem's guideline before your consultation. See the full Schnur scale and calculator.
Dr. Kiwanuka works with Anthem members through their out of network benefits. More than 95% of the insurance requests we submit are approved. Here is how the process works.
Our team
We check your plan's out of network benefits, deductible, coinsurance, and referral rules at no cost.
You and Dr. Kiwanuka
Dr. Kiwanuka examines you and plans your reduction. Consultations are complimentary for insurance patients.
Our team
Clinical photographs, records of prior treatment, and a letter of medical necessity written to Anthem's criteria.
Our team
We submit your request to Anthem and follow up until a decision is made.
All patients photographed with informed written consent. Individual results vary and are dependent on anatomy, procedure type, and recovery.
Often, yes. Anthem covers breast reduction when it is medically necessary: breasts large enough to cause physical symptoms that have not improved with treatment. Your symptoms and the planned tissue removal must meet Anthem's guideline, and your plan must include the benefit.
Yes. Empire BlueCross BlueShield now operates as Anthem Blue Cross and Blue Shield in New York. Breast reduction requests are reviewed against Anthem's clinical guideline, CG-SURG-71.
Anthem's guideline asks for upper back and shoulder pain that interferes with daily life, rashes beneath the breasts that resist treatment, shoulder grooving with ulceration, or thoracic outlet syndrome; at least 3 months of conservative treatment for pain; your height, weight, and breast size; and planned removal above the Schnur scale minimum for your size, or at least 1 kg from each breast.
Yes. Anthem uses the Schnur Sliding Scale at the 22nd percentile, based on body surface area. Removal of at least 1 kg from each breast qualifies at any size. You can estimate your number with our Schnur scale calculator.
For pain, Anthem asks for at least 3 months of conservative treatment, such as support garments, pain medication, or physical therapy, before surgery.
Yes. Every breast reduction reshapes the breast and moves the nipple higher, so the lift is part of the operation. A lift on its own, without a reduction, is generally considered cosmetic.
Dr. Kiwanuka works with Anthem members through their out of network benefits. Benefits vary by plan, and our team checks yours for free before you schedule. You may request a written estimate of what we will bill at any time.
We review the reason and, when appropriate, send more documentation or an appeal. You also have appeal rights through Anthem, and some denials qualify for an independent external review.
Share a few details and our team will check your breast reduction benefits at no cost and with no obligation. Prefer to write? Contact us.
Verification confirms your benefits. It is not a guarantee of coverage or payment.