Will Blue Cross Blue Shield Insurance Cover Breast Reduction Surgery if Its Deemed Medically Necessary?

I'm 5 foot 2 in, about to 21 years old and I weigh about 130 or a little less. I went to a chiropractor for about 4 years but all it did was help with my headaches which I've had since the 1st grade. I'm about a 38/40 D and I have severe back/shoulder/neck pain, I have to sleep with a heating pad on my back under my shirt in order for me to sleep cause its the only thing that alleviates the pain to where I'm comfortable. Am I good candidate? I've also tried losing weight but nothing happened.

Doctor Answers (8)

BCBS coverage?

+1

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.
Best wishes,

Dr. Basu
Houston, TX


Houston Plastic Surgeon
4.5 out of 5 stars 113 reviews

Insurance coverage and Breast Reduction

+1

Based on your measurements you seem to need a breast reduction. Getting breast reduction covered under insurance is very difficult. In fact getting them to tell you, as the consumer, the number of grams needed to get coverage will be nearly impossible. I suspect in the end it will have to be paid out of pocket.  The insurance frequently places the restrictions without any medical substantiation. I have had many difficulties with my own patients getting coverage. The best way to get coverage is to call your insurance company...remember you are the consumer.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 13 reviews

Insurance coverage for breast reduction

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is available if your exam confirms that the minimum amount of breast tissue by weight as determined by your height and weight can be removed and still leave you with a size you are happy with.  Your surgeon should be able to help guide you through the process and the authorization process could be drawn out if you do not have documentation of the problems/symptoms being refractory to conservative medical management.  Good luck with  getting the procedure and results that you desire.  Remember that this will affect your abilty to breast feed in terms of milk production.

 

Curtis Wong, MD
Redding Plastic Surgeon
4.5 out of 5 stars 16 reviews

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Breast Reduction and Insurance Coverage?

+1

Thank you for the question. Based on your description, you may be an excellent candidate for breast reduction surgery. It sounds like you have been  dealing with  breast hypertrophy for several years, along with the physical and psychosocial consequences of this diagnosis. In other words, the breasts are too large for your frame causing both physical and psychological distress.

As  you think  about  breast reduction surgery make sure you do your homework and understand the potential risks and complications associated with  the procedure.  Unsatisfactory scarring is  one of the potential complications. Make sure you also understands that further surgery may be necessary in the future (for example if the breasts were to grow in size again).


On the other hand, breast reduction surgery is one of the most patient pleasing operations we perform and I think that for the right patient (enough symptoms) it may be an excellent option (regardless of the age).


Sometimes breast  reduction surgery is covered through health insurance. The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.
Make sure you are  working with a well-trained/experienced board-certified plastic surgeon.



I hope this helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 680 reviews

You should get insurance coverage for breast reduction.

+1

Hi.

I hope this article is useful. 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.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance for a Breast Reduction?

+1

Most insurance carriers cover breast reduction but always with limits. The biggest limit is how much weight is to be removed from each breast. You will need to see a surgeon to determine that and then the doctor's office will contact your insurance company to see if you meet their guidelines.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 12 reviews

You can be sure about breast reduction coverage after predetermination

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All Blue Cross plans in Illinois are not alike and the only way to know if reduction is an allowed benefit and under what conditions, is to have the surgeon submit a predetermination request, with a written response in return. We feel you are a good candidate, however insurance coverage has become difficult for many.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 26 reviews

Insurance coverage for breats reduction

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You are certainly a good surgical candidate. In terms of insurance coverage, check the provisions of your insurance policy. These should be accessible on BC of Illinois' website under breast reduction criteria. Obtain all the chiropractic records, not just a letter and provide them to your plastic surgeon. His office should be able to evaluate the criteria and determine whether you fulfill them. In NY, Blue Cross issued predeterminations but, if memory serves me correctly (I perform a lot of breast reductions and have had patients with BC of Illinois because their employers were based in Chicago), BC-Illinois may not issue written authorizations. In that case, it is very important to make sure that you do fulfill the criteria so you aren't stuck with the bill at the end of the day. Best of luck.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 8 reviews

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.