Is there any way that BCBS would cover a breast reduction and a panniculectomy for the purpose of relieving osteoperosis? Can these surgeries be tied into a mental health issue? I have a 25-pound pouch that hangs lower than my hooha, itches, and my breasts are down to my belly button. I've had lapband surgery but wasn't successul. I have maintained the same weight for 2 1/2 years now, losing the same 10 pounds over and over. I'm stable. I just want the fat cut off (a mini tuck?) and the boobs cut off to alleviate pain and more loss of bone density due to the extra weight tugging on my spine.
BCBS Insurance Coverage for Breast Reduction and Panniculectomy?
Doctor Answers 12
Insurance coverage for breast reduction
Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.
Breast Reduction, Panniculectomy and Insurance Coverage?
Thank you for the question.
It is possible that these procedures will be covered by your health insurance. You will need to submit as much supportive paperwork and pictures as possible and be prepared to be persistent.
Insurance coverage for breast reduction.
Insurance Coverage for Breast Reduction
Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
Contact the doctor
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.
1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.
2) Very big reductions (like from an F cup to a C cup) will usually be covered.
3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.
4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.
5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.
6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.
7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.
8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.
9) Don't give up. If the first request is denied, demand an appeal.
10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.
Helpful?Last modified 24 days ago
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Insurance Can Help if You Have Medical Issues
It sounds like the rashes plus the pain from the osteoporosis that is being aggravated by your large breast size may make you a candidate for coverage.
Visit http://www.drlomonaco.com/patient_resources.html and you can download an article called "Tips on getting Insurance Coverage"
Insurance coverage for breast reduction and panniculectomy
Every insurance company is different. For your breast reduction, see your plastic surgeon for specific details about what is required to get this covered. Photos may need to be sent in and a certain amount of tissue may have to be removed. Concerning your panniculus, photos and preauthorization will most likely be required. Good luck!
Forget about the osteoporosis
No insurance will cover reduction surgery, breast or abdominal, on the basis that it will alleviate osteoporosis. The fact is, osteoporosis is not caused or worsened by large breasts or an abdominal pannus. Concentrate more on the pain and rashes in your quest for insurance coverage. There are several plans within BCBS, some of which may cover your procedures and some of which may not. Consult with a board certified plastic surgeon who can take photographs and pre-authorize/pre-certify your surgery with the insurance carrier. This way you will for sure whether coverage is available. A call to your insurance plan may also provide you with coverage information. Good luck!
Unlikely that BCBS will cover this, but you should call
In general, BCBS is terrible about covering these procedures. On the other hand, most insurance companies hate to talk with patients. Give them a call. You will most likely speak with a nurse evaluator who will let you know how to proceed. If she gives you an option to see a physician, take it. See a qualified Plastic Surgeon and have them submit a letter for pre-authorization. If you follow the steps, you will know your out of pocket costs.
Insurance coverage for pannus and breasts
Insurance will sometimes cover breast reductions and pannus excisions for select conditions. For the breasts if there is documented symptoms and conservative treatment failure it may be possible. For the pannus, if there is a documented history of infections or rashes not amenable to conservative treatment, this may be covered
Insurance coverage of procedure
You should first schedule an appointment with a particpating provider and then discuss the planned procedure. If you are a candidate, then have the surgeon compose a predetermination of benefits letter to ascertain your elegibility for coverage.
BCBS insurance coverage for Breast Reduction and Panniculectomy
There is NO WAY to convince any insurance company of anything they they do not HAVE to do. They are only obliged to "cover" (which is NOT the same as "to pay") the items on your policy.
IF your policy HAS a rider or "benefits" for breast reduction and for a panniculectomy - then - subject to meeting their criteria and finding a surgeon who will accept their payment - you can have these operations. If you policy does not have such benefits, you can try any recourse you may want, but they are not obliged to "cover" a service(s) for which you did not pay premiums on.
PANNICULECTOMY - from your vivid description, OBVIOUSLY, you would do great with such a procedure. BUT - again - does your policy provide it as a benefit? If it does, look and see WHO the local Plastic surgeons are who work with (IE "are providers for...") that policy. Check them against the listings of the American Society of Plastic Surgeons (www.PlasticSurgery.org) and see a few. They will tell you how to proceed and what supportive documentation you may need.
BREAST REDUCTION - same thing. If it is a benefit under your policy, a plastic surgeon who takes that policy (IE "is in network"...) will guide you as to what is needed and if he/she thinks you are a good candidate.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.