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Insurance Coverage for Reduction / Correction of my Uneven Breasts?

I went to a plastic surgeon, and he said that most insurance companys would cover my surgery because of the fact I'm in really bad back pain and the larger of the two breasts is a 32ddd and weighs about 2 pounds. The smaller is small 32d to large 32c (in 5'3, 108 pounds). I would be getting a reduction on the larger one and that is it. He was pretty confident that I would be covered until I mentioned I had coventry insurance. how can I get them to cover it?

Doctor Answers (11)

Breast reduction and insurance companies

+2

Take a look at your insurance policy Explanation of Benefits- if breast reduction surgery is listed as a benefit for YOUR policy, and your a reasonable candidate with good documentation- then there is a good chance insurance will cover the claim. BUT, if your personal policy does not cover breast reduction surgery- there is no way it will be covered. You get what you pay for.

Web reference: http://www.scottsattlermd.com

Seattle Plastic Surgeon
4.5 out of 5 stars 32 reviews

Insurance

+1

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.

Houston Plastic Surgeon
4.5 out of 5 stars 36 reviews

Breast Reduction and Insurance Coverage?

+1

Thank you for the question.

Based on your description you may be a good candidate for breast reduction surgery.

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. If your request is denied an appeal may be necessary.

Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.

Best wishes.

Web reference: http://www.poustiplasticsurgery.com/Procedures/procedure_breastreduction.htm

San Diego Plastic Surgeon
5.0 out of 5 stars 626 reviews

Insurance coverage and breast reductions

+1

Each insurance company has their own criteria for coverage of a breast reduction . The best thing to do is call your company and find out.

Manhattan Plastic Surgeon
4.5 out of 5 stars 14 reviews

Insurance coverage of breast reduction

+1

Your physician may have had previous more qualified patients who were denied by Coventry and he/she may be speaking from experience. You could ask for a predetermination of benefits letter to ascertain your coverage prior to surgery. This likely would require photographs. Supporting documentation from your other health care providers including chiropractors, physical therapists, and primary care physician could be beneficial to support your case.

Web reference: http://www.bodysculptor.com/breast-surgery-chicago/breast-reduction/

Chicago Plastic Surgeon
5.0 out of 5 stars 39 reviews

Call your insurance company!

+1

Check with your insurance company yourself.  See whether or not your policy covers breast reductions.  The code to give the insurance company is 19318-50.  In Atlanta, Coventry does pay for breast reductions that are medically necessary.

Atlanta Plastic Surgeon
3.5 out of 5 stars 7 reviews

Breast reduction insurance coverage

+1

Most insurance companies are now using the Schnur scale to determine coverage for a breast reduction. This takes into account height, weight and then amount of breast tissue to be removed.  Each insurance company is different. The most important thing is for you to contact your insurance company and ask them for the criteria that are used for coverage of breast reduction. Then take that information to your doctor and that should help get the process going.

Hope that helps.

Josh Korman MD

Monterey Plastic Surgeon
5.0 out of 5 stars 2 reviews

Insurance Coverage for Reduction / Correction of my Uneven Breasts?

+1

Regarding: "Insurance Coverage for Reduction / Correction of my Uneven Breasts?
I went to a plastic surgeon, and he said that most insurance companys would cover my surgery because of the fact I'm in really bad back pain and the larger of the two breasts is a 32ddd and weighs about 2 pounds. The smaller is small 32d to large 32c (in 5'3, 108 pounds). I would be getting a reduction on the larger one and that is it. He was pretty confident that I would be covered until I mentioned I had coventry insurance. how can I get them to cover it
?"

Most American are rightfully confused by Health Insurance. When you or your employer purchase coverage you are paying for a SPECIFIED list of items that will be covered AND you agree to pay an agreed upon charge per visit (IE copay) and per year (deductible).  

In YOUR state Coventry sells MULTIPLE products: CMR, GHP SO, HMO/POS, PPO, PPO Select and Coventry National Network in addition to its Medicare and Medicaid networks. EACH one of these then sells different contracts of covered services to employers and individuals. EACH contract is different. Usually, the more expensive the policy the more items would be covered.

Just because you have "Coventry" or BlueCross Blue Shield" does not mean that a particular medical service would be "covered". To find out if it is, consult your book.

IF you do not have "Breast Reduction" benefits, it means you did not buy and pay for such coverage and despite any letters or protestations, the company is within its legal right NOT to give you a service you did not purchase.

Look in your book to see if you have such coverage AND which Plastic surgeons in your area accept your plan. I would then meet with them and be guided by their advice. They will know what will or will not be covered.

Good Luck.

Dr. Peter Aldea

Memphis Plastic Surgeon
5.0 out of 5 stars 52 reviews

Insurance Coverage for Breast Reduction

+1

Insurance Coverage for Breast Reduction

Article 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.
 

Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance Coverage for Reduction / Correction of my Uneven Breasts

+1

My best advise is the see in person the insurance plan's plastic surgeon provider. That doctor will know if you are covered by that insurance plan and will take the necessary steps to obtain a letter of predetermination of benefits for you. You can also call your insurance company to discuss with them the necessary steps to obtain this letter. You need something in writing for your protection. Best of luck. From MIAMI the "real" Dr. Darryl J. Blinski 305 598 0091

Miami Plastic Surgeon
4.5 out of 5 stars 55 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.

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