What is Needed for BCBS of PA PPO to Cover for my Breast Reduction?

  • West Palm Beach7192
  • 2 years ago

I'm 29 yrs old 4'7" tall and 110 pounds. Im a 34 DD and I will like a reduction but I don't want to be left with no breast since I understand there is a 500 grams that the insurance usually required to be reduced. What  do I need to do in this case I don't have documentation of back pains etc, I do suffer from all those symptoms but I never been to the Dr for it. Everything started getting worse after I had my son two yrs ago then I became a 34 DD I used to be 32 D it may not sound so bad but because of my tiny frame I had always had back problems I cant even sit up straight anymore. What do I do now? Will my BCBS of PA cover my surgery even if I live in FL?

Comments (4)

I have BC/BS of PA and had my consultation with my PS on Oct 31st. I got my approval from insurance in about 2 weeks which surprised me that it was so quick. I am 5'2", weigh about 110 lbs and am petite frame as well. I was a size 34DD-DDD and am now, I believe, a C (will know more accurately once my swelling goes away). I too had back, neck & shoulder pain but felt relief almost immediately after surgery. I believe my PS took about 450 gms from my left and 500 gms from my right - but am not absolutely sure of the exact numbers. I did not have to go to any other doctors for add'l treatment or documentation. The PS should be able to give you a good idea of how much he will need to remove without comprimising your breast & size. Mine told me up front I'd end up being a C. I'm thankfully very pleased with my outcome. Good luck to you & please keep us posted!
  • Reply
The best way to get this answered is to call your company. I had all of the criteria for my insurance (BCBS of Ill) and accurate documentation and still contacted my insurance company to get my questions answered. My approval came within 2 weeks and my surgery came 1 week later. Many blessings as you proceed!!
  • Reply
P.S. my dr removed 360 gm's from one and 380 gm's from the other, it all has to do with the Schnur scale formula.....500 gm's or more is just a basic guideline.
  • Reply
I don't know about PA, but for BCBS of Georgia they would do them under 500g, but you had to meet an extra criteria. So if they were moving over a total of 1000g per breast you could have one of the following: back pain for at least a year that was documented to interfere with life or work, rashes under the breast or shoulder grooves that do not respond to "conventional treatment", thoracic outlet syndrom (don't know that that is!). If they were removing under a total of 1000g then you had to meed TWO of the criteria.

As to the second part, mine is through BCBS of Ga and I live in California now. I actually couldn't find anyone who covered me in the end :/ In theory I found a bunch of docs who said they would, but once they sat down and looked at the fine print of my plan none of them wanted to work with me. I ended up paying out of pocket. I had this weird experience where I would call doctors and and say "do you take blue cross blue shield of Georgia?" and they would say yes... Then after the consult the billers would tell me "this plan is not good and we can't use it." It literally happened to me three times! Then a fourth time I went to an IN NETWORK doctor, and she simply never submitted the paperwork to the insurance after the consult, then never returned any of my calls. It was very weird. Of course, this may have only to do with BCBS of Georgia!

The way one biller who was kind enough to explain to my why they wouldn't take my insurance explained it, the insurance companies pay what is "customary" to the doctor and they do that by zip code... So if I bought my plan in PoDunk Ga (I did :p) where the average breast reduction is only 5,000, and now I am living in LA where it is 9,000 no doc in LA is going to take the 5,000.
  • Reply