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All insurance companies are in business to make money. They do that by taking in more money than they spend on covering their insured population. If they can deny coverage they make more money. They used to publish what was required weight wise for a breast reduction t be covered. These days they don't tell the doctor or the patient. It is that possibility of you having to pay for your surgery that discourgage you from proceeding and is what they count on to make money.
You can try to get precertified for the procedure based on symptoms. Remember, the squeaky wheel gets greased. Keep after them and don't give up until you get the answers you deserve about why or why not they will cover your procedure.
Best of luck
A. Dean Jabs, MD, PhD
Board Certified Plastic Surgeon
Bethesda, MD/McLean, VA
Breast reduction, or reduction mammaplasty patients are among the most satisfied of all plastic surgery patients. Large breasts (macromastia) can often decrease quality of life for a woman. With breast reduction, you can have smaller breasts that sit higher on your chest wall. You will also find relief in your neck and back with the decrease in weight and more ergonomic position of your breasts.
There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.
1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.
2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.
3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.
Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.
The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!
Insurance covering Breast Reduction
BCBS in Texas is one of the best companies to approve breast reduction cases in our office experience. There are guidelines they go by such as amount of breast tissue to be removed from each breast. The symptoms they cover for are neck,shoulder,and back pain and intertrigia(growth under breast). Your doctor should be able to tell you in consultation if you have a good chance to get your case covered. Photos of your breast are submitted with your information. Turnaround time is usually 6 weeks. Go in early before the end of the year if you are planning to use your deductible so you can get your case approved and scheduled.
Blue Shield will most likely cover Breast Reduction
Most likely BC/BS will cover your surgery. Consult with a plastic surgeon (I recommend a board certified plastic surgeon by the American board of plastic surgery, the only board in plastic surgery by the American Board of Medical Specialties).
This doctor will examine you and document that you are a good candidate for the procedure. He will send a precertification (request for approval for surgery) letter to your insurance and after 4 to 6 weeks the insurance will respond, either approving or denying the surgery.
Will Blue Cross Blue Shield Cover Breast Reduction
Thank you for submitting your question. Yes you seem to be a good candidate for a breast reduction and with your symptoms, height and weight, you will most likely be approved. Please visit with a Board Certified Plastic Surgeon in your area. best wishes.
Blue Cross Blue Shield generally will cover a breast reduction if you meet their criteria. Usually that includes, back and neck pain, rashes under the breasts, and large breasts (which are large enough). If you have the right symptoms but the breasts aren't large enough, they may not approve the surgery. Your surgeon will be able to tell you during your consultation if they are large enough to gain approval from BCBS.
Insurance May Cover Breast Reduction
It is not possible to guarantee insurance coverage for breast reduction, but there are several factors that insurance companies typically use to evaluate reimbursement for breast reduction surgery: history of breast pain, neck-, back-, shoulder-pain, that haven't been relieved by medication, exercise, physical therapy; pain with exercise or interference with exercise; recommendation for breast reduction and documentaion by physical therapist, primary care doctor, orthopedic surgeon or neurosurgeon; the amount of breast tissue removed at surgery.
Be sure to check with your insurance company and submit documentation before surgery.
Insurance and breast reduction
Insurance companies are getting harder and harder to work with, particularly for breast reduction to be covered. Some companies have started to exclude covering this surgery all together. I find this offensive and ridiculous.
BCBS should cover the surgery (and hopefully you've had it by now).
Hopefully you've found a good plastic surgeon to take care of you.
Insurnance coverage of breast reduction surgery
It is difficult to predict without more information whether your insurance company will cover the surgery. Every insurance company has different requirements, and some companies will pre-authorize surgery while others will not. In general, the insurance companies will want to know if you have back pain, neck pain, shoulder pain, shoulder grooving, and if you get rashes underneath your breasts. They want to know if you have tried other things to alleviate your symptoms. At the end of the day, one of the main things they care about is how much breast tissue is removed from each breast. They sometimes use complicated formulas to come up with a weight that must be removed in order for the procedure to be covered.
You can call your insurance company and ask about their specific requirements.
Insurance coverage for breast reduction
Health insurance agencies will typically "cover" breast reduction operations if you adhere carefully and qualify based of their criteria. It may be helpful to call your health insurance provider and find out what their specific criteria may be. Each Insurance agency differs. Oftentimes quite a bit of documentation must be provided by you and your primary care physician to help prove that you have met the insurance criteria. A consultation with a plastic surgeon can also help you find out if you are a good candidate for breast reduction and if you are likely to be able to meet Insurance criteria.