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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
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.
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.
Will Blue Cross Blue Shield Cover Breast Reduction?
In general, approval from an insurance company for a breast reduction involves meeting several criteria. Each insurer will have a minimum resection volume (weight) of breast tissue that they consider constitutes a medically necessary reduction, often in the range of 400- 500 grams. An experienced Plastic Surgeon can estimate the expected volume of resection. Some insurers use the Schnur Sliding Scale that is used to determine an appropriate cut-off for breast reduction resection weights based on the patient's height and weight. Some will use Body Mass Index as an exclusion criteria if the patient is deemed overweight resulting in large breasts Your best bet is to contact your insurer and find out what the specific criteria are for you.
In addition, in the approval process your doctor(s) should document persistent neck and shoulder pain, painful shoulder grooving from bra straps, frequent rashes of the inframammary fold, and frequent episodes of headache, backache, and nerve symptoms that are the result of large breasts.
Some insurers require a period (often 6 months) of conservative management for musculoskeletal symptoms with physical therapy, although this has not been shown to be a successful treatment. In addition, physical therapy will not address many of the other symptoms including bra strap grooving, rashes, inability to function social and in athletic endeavors to name a few.
Photographs are a key component of the pre-authorization process. A picture can convey the true nature of the problem that might not be clear from the objective data submittted.
Unless you have other problems that might prevent you from having surgery, it sounds like you should be a good candidate. The sooner you see a Board Certified Plastic Surgeon, the sooner you can get your approval process going.
Will insurance cover my breast reduction?
Insurance requirements vary from plan to plan and also within plan subtypes. The only way to know is to be evaluated by a plastic surgeon. If you are found to be a candidate for the surgery, a pre-authorization is submitted to the insurance to see if they "approve" it or not. Approval depends on the plan and it's requirements AND on whether or not they find it to be "medically necessary". Note that even if they approve it based on medical necessity, there is always a chance that they will deny it later since they state that "approval is not a guarantee of payment".
That being said, there are definitely factors that affect medical necessity. For example, if you answer yes to multiple of the following questions, there is a good chance that a good insurance plan will cover it, particularly when there are months of medical documentation to support it:
1. Have been to a doctor in the past 2 years to discuss pain due to large breasts and neck/shoulder/back pain?
2. Have you ever had an infection or rash under you breasts for which you have been to the doctor?
3. Have you ever been sent to physical therapy or a chiropractor?
4. Do you take medications often for the pain?
5. Have you ever had xrays or an MRI of the neck or back?
It sounds like you would be able to get your surgery covered by insurance because of the pain you're feeling. Consult with a board certified PS who will examine you and make sure breast reduction is right for you. They will then help you get insurance approval.
Insurance coverage of breast reduction varies by company
Each company has different requirements for covering breast reduction. But they all look at similar factors.
- Do you have symptoms caused by having large breasts? These include neck and back pain, grooving in your shoulders from your bra strap, breast pain, and rashes under the breasts.
- Have you tried nonsurgical treatment for these symptoms? This may include over-the-counter or prescription pain medication, seeing a chiropracter, physical therapy, wearing a sports bra, using ice or hot packs, and using topical creams for any rashes.
- Have other causes of these symptoms been ruled out? Your primary care doctor can assess this for you.
- Will enough tissue be removed? Every insurance company has a different minimum number, and it varies by your height and weight as well. Your plastic surgeon will estimate this number during your consultation.
A quick call to your insurance company can help you find their specific requirements.
Breast reduction covered by insurance
Depending on your situation, insurance may be able to subsidize the cost of breast reduction. Some breast reduction coverage requirements where I practice in Ontario include your current cup size, the amount of breast tissue removed during surgery, unsuccessful experiences with alternative treatments and medications, as well as recommendations for breast reduction from other specialists, such as chiropractors and neurosurgeons.