Average Allowable Amount for Breast Reduction

I have Blue Cross/Blue Choice of Sc breast reduction surgery is covered if I meet criteria, which I do. I have contacted an in-network Dr. surgeon fee is $4900, the facility fee is $800, anesthesia $580 is not covered. I must pay $250 deductable, $100 co-pay, $580 anesthesia, and 15% of the allowable amount. Neither the Dr. office or my insurance will tell me what the allowable amount is. Is there an average percent reduction off of the original surgeon's fee?

Doctor Answers 3

Insurance coverage

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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

Allowable Fees For Breast Reduction

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The fees which insurance companies pay plastic surgeons for breast reductions is typically quite low, especially for a procedure which is quite time comsuming.  I have never practiced in South Carolina, but I doubt that there is a great difference in the allowable fees between there and Kentucky.  Therefore, my guess is that the allowable would be $1,300-2,000.  If you look around, you probably can find a hospital and anesthesiologist who participate with BC/BS which would lower your out-of-pocket costs.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Breast Reduction Surgery

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Unfortunately, insurance companies are difficult to work with when you are trying to get an exact number that they will pay.  They usually do not want to commit to anything prior to surgery. Sorry that I cannot assist you further, we have had similar issues and it’s hard to predict.

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