Breast Reduction and Lift Insurance Coverage Requirements?
- Asked by shannonskinner in Las Vegas
- 4 years ago
I am a healthy 28-year-old. I was a 34 DD before having kids. I am 5'3" and weigh 150 lbs. I have 10 more lbs to go before I meet with a surgeon. My breasts used to be firm, perky and although large, very nice. Now they are saggy, huge and limp.
I would like to get a breast lift and breast reduction. I have BCBS of NJ, but live in Las Vegas. I will be done nursing in March. They are now larger than a 36F. Whats the next step? I want to be a 34 large C. I am wearing pink in the photo.
Insurance coverage for breast reduction.
Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
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.
Breast reduction by insurance or not
I can clearly understand that you want your reduction to be done under your insurance and you can certainly visit surgeons who can write letters to your insurance seeking preauthorization of coverage. But please also know that these are the only breasts you will ever have and many of the very best plastic surgeons no longer work with any insurance as the reimbursement for a breast reduction to the doctor can be as low as a few hundred dollars depending on the insurance. This doesn't even cover the doctor's cost of doing the surgery. So you might want to find the very best surgeon even if they don't take insurance and have them discuss this with you. Look at lots of photos and go to the best doctor regardless of insurance.
Web reference: http://www.randcosmeticsurgery.com
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.
Recent Breast Reduction Reviews
Breast Reduction Photos
Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage. Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed. If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay. Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee. There is a geographic difference as well. It will vary from $8000-$10,000. Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits. Good luck to you.
Insurance and breast reduction
Reductions can be done as early as 15 with parental consent, a proper medical clearance and breast growth that has stopped. Insurance coverage is a hit or miss depending on the carrier. Usually having symptoms related to breast size is necessary for insurance coverage. Getting it covered though is very difficult. Insurance companies wont tell anyone how much tissue needs to be removed to qualify for coverage. Then if the surgeon is 1gram off they deny coverage after the fact. Insurance companies make money by denying coverage. For that reason most plastic surgeon will likely ask for payment up front. Breast reductions are the most gratifying operations because years of neck, back and shoulder pain are gone within days. The final size result depends on your starting size. If you start larger then you will likely end larger. It is not possible to choose a size with any real accuracy. The main reason is that the procedure removes breast tissue but leaves enough tissue to preserve the blood supply to the nipple and areola. Thus more tissue needs to be left behind to ensure nipple viability. The nipple and areola is constantly being accessed during the operation. See a board certified plastic surgeon for specifics on your treatment.
Breast reduction insurance coverage
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're saying a well-trained/experienced board-certified plastic surgeon. Good luck!
Breast Reduction Timing after Breastfeeding and Insurance Coverage
Since you are young, the first question for you to consider prior to undergoing any breast reduction surgery is whether or not you plan to have any more children, and if the answer is yes, do you wish to breastfeed? I recommend to all my young female patients to finish having their children and finish breastfeeding since, as you have experienced, your breasts will grow, change size, change shape, then "deflate" (something we call "involutional hypoplasia") over time. Also, if you wish to maximize your ability to breastfeed in the future, then you should not undergo breast reduction surgery until you've completed having children.
Once you have decided that it is time for you to undergo a breast reduction, you should try to reach your goal weight first so that your breast volume is stable. Insurance companies will typically cover breast reduction surgery if the claim has evidence that the patient suffers significant disability and pain from the size of her breasts (such as chronic neck, back, shoulder pains, headaches) or other problems such as chronic rashes beneath the breasts, 'bra-strap' grooving deformity of the shoulders and impedence of one's ability to exercise appropriately due to the large size of her breasts. It is important to document that treatments to try and alleviate the problems have been tried and failed- such as chiropractic treatments, physical therapy, weight-loss without a reduction in the size of the breasts, dermatologic treatments for skin-rashes, etc. Finally, most insurance companies are now requesting photographs of patients' breasts along with the paperwork claim, as well as some sort of documentation that the surgeon plans to resect at least about 500 grams of tissue from each breast.
Understand that lifting of the breast (breastlift) is an inherent portion of a breast reduction procedure, and that the breasts become both reduced and lifted at the same time. A breastlift is deemed cosmetic if no significant amount of breast tissue is resected. Be sure that your surgeon sends any resected breast tissue to pathology for final examination. If you are 40 years old or older, it is imperative to get a mammogram prior to any breast reduction surgery.
Insurance Coverage for Breast Reduction
Most insurance companies look at the BSA. This is the body surface area which is a ratio of your weight and height. This is obviously besides your complaints of neck pain, back pain and shoulder grooving. When calculating the BSA you will be give a number like 1.4 or something. This is take and looked at on a sliding scale to determine how much breast tissue needs to be removed per side in grams. If this is the amount to be removed or more then insurance company will likely cover the procedure.
So, you need to go see a board certified plastic surgeon to go over things as well as take photos to send to the insurance company.
Insurance usually covers breast reduction as a medically mandated procedure
Breast reduction is usually covered by insurance when the surgery is performed as part of a medically mandated procedure to treat neck, back, or shoulder pain or other problems related to the spine. Recently, managed care has adopted stricter standards for coverage, so these problems have to be thoroughly documented in writing by your primary care physician and plastic surgeon. They may also have to submit photographs. Even then, you may be required to seek a second opinion from a chiropractor, physical therapist, or orthopedic surgeon.
Large breast reduction surgeries can usually be covered by insurance
Usually large breast reductions can be covered by insurance, but it is getting tougher. The insurance companies usually want documentation of back, neck and shoulder pain that has been treated by conservative measures but with little to no success.
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.