Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Please check your insurance policy to see whether breast reduction is a covered procedure. Often times, insurance company will dictate how much breast tissue to be removed. Please visit an experiences, board-certified plastic surgeon to learn about the procedure, its cons and pros, benefits, and alternatives. Please contact your insurance carrier to learn about inclusion and exclusion criteria. Best wishes.
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.
Will Blue Cross Blue Shield Cover Breast Reduction?
Thanks for your question. Not all insurance polices are the same. Even though some BCBS policies cover breast reductions, there may be some that have exclusion clauses. You can speak with a "member's benefit" representative from BCBS to see if your policy covers breast reductions. If they do, the symptoms you are describing will provide a strong case to be eligible for coverage.
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.
Each individual insurance provider has specific criteria that must be met in order to consider coverage. I suggest you check with your insurance carrier and ask them what their criteria are. It may be listed on their website. It may be difficult for you to determine if you meet the criteria. I recommend a consultation with a board certified plastic surgeon that will submit your information for prior approval to determine if it will be a covered procedure.
Insurance Coverage for Breast Reduction
The best advice I can give you is that documentation is key when it comes to trying to get insurance companies (independent of carrier) to cover a breast reduction surgery. Each insurance carrier has set forth a set of criteria and guidelines, which can be found online and must be met, for a case to even be evaluated for medical necessity.
Most insurance companies like to see photographs and documentation from specialists and physicians across various medical specialties (including plastic surgeons, internists, orthopedic surgeons, chiropractors, physical therapists and dermatologists) attesting to the severity and length of the problem and what they have tried in the past to alleviate the issue or hardship prior to a patient's turn to plastic surgery. Symptoms that these guidelines cover include neck, shoulder and back pain, shoulder grooving, failed physical therapy or minimal improvement, intertrigo, etc...
I would recommend consulting with a board-certified plastic surgeon who will conduct a physical examination and document the necessity and that you are a good candidate for a breast reduction procedure. Their office should also gather all necessary supporting documentation and submit to your insurance company for any pre-certification or pre-approval. It takes roughly 4-6 weeks to hear back from most carriers, so be patient and remain hopeful. I hope this helps!
Most Blue Cross Plans Cover Most Breast Reductions
Most insurance companies have seen the wisdom of large outcome studies that show that breast works to decrease or eliminate the symptoms of large breasts. Back pain, neck pain, shoulder grooving.
See your plastic surgeon for an evaluation to see if you meet the criteria on your Blue Cross plan. Most plans require documentation of symptoms, measurements and photos, then require a certain number grams of tissue resected based on your height and weight. (Schnurr formula is used by many).
Bottom Line: High likelihood that you can get coverage! But unfortunately, a few plans exclude breast reduction and a few have conditions which squeeze some marginal cases out.
If if you find out that you are not covered, most plastic surgeons offer for a 'cash' price, and it is still worth doing!
Insurance and Breast Reduction
If you schedule a consultation with a Plastic Surgeon, their office staff should be able to look at your insurance and give you a fairly good idea of how much they would pay towards a breast reduction. They should also be able to guide you in submitting the appropriate paper work to get preapproval for the procedure.
Will Blue Cross Blue Shield Cover Breast Reduction
Thank you for submitting your question. Yes you seem to be a good candidate for a breast reduction and with your symptoms, height and weight, you will most likely be approved. Please visit with a Board Certified Plastic Surgeon in your area. best wishes.
Breast reduction, or reduction mammaplasty patients are among the most satisfied of all plastic surgery patients. Large breasts (macromastia) can often decrease quality of life for a woman. With breast reduction, you can have smaller breasts that sit higher on your chest wall. You will also find relief in your neck and back with the decrease in weight and more ergonomic position of your breasts.
There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.
1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.
2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.
3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.
Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.
The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!