Insurance coverage for Breast Reduction with Geisinger HMO?

Question

I'm 5'5 147lbs and wear a 34ddd I had a consult with my PS who said he can remove 500+grams. I have been suffering with neck and back pain and it hurts to SLEEP. I was just wondering what my coverage odds are and if anyone has had experience with my insurance?

Larry S. Nichter, MD, MS, FACS · Answer

Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions. This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems you are experiencing secondary to breast hypertrophy; based on your description you may be an excellent candidate for breast reduction surgery at some point.   “Official” recommendations of course would necessitate in-person consultation.Breast reduction surgery is one of the most patient pleasing operations we perform. By removing “excess” breast tissue, adipose tissue, and breast skin  this operation reduces AND lifts the breasts to a higher position on the chest wall (in other words, the breasts are "automatically" lifted when a breast reduction is performed). By doing so, patients often find improvement in neck, back, and shoulder discomfort and find it easier to form their activities of daily living and exercise. Obtaining insurance coverage for breast reduction surgery will likelyinvolves 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 letters/pictures from your plastic surgeon will help you obtain authorization.  Prepare to be persistent when dealing with health insurance companies.When the time is right,  seek consultation with well-trained/experienced board-certified plastic surgeons. Ask to see lots of examples of their work and communicate your goals clearly.I hope this, and the attached link, helps.  Best wishes as you work towards your goals.

C. Bob Basu, MD, MPH, FACS · Answer

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. BasuHouston, TX

Insurance coverage for Breast Reduction with Geisinger HMO?

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Insurance coverage for Breast Reduction with Geisinger HMO?

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Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.