Will BCBS of CA PPO Cover my Breast Reduction? 34 G -34 H 0% Padded Bra. (photo)

Hello I'm sure my question said it all in a nut shell. In my case, ah, (in two heavy kegs)! I'm 45 yrs. old, 149 lbs., 5 4", small to med. build short waisted big breasted woman. I'm relatively toned and have dieted all of my life with the main reason my breast are very dense and obviously so large that I've been too thin but yet my breasts uncomfortably large. 1.). Will my Ins. cover this operation? 2.). How much, just approximately do you think my breasts may weight? 3.). 34 G to 34 C ?

Doctor Answers 9

Insurance and BR

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From your description it seems as if you are a good candidate for breast reduction. 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Will BCBS of CA PPO Cover my Breast Reduction? 34 G -34 H 0% Padded Bra.

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Hi Cherincoronado. It’s understandable that you’d want to have a breast reduction. My breast reduction patients usually experience a lot of physical problems from their heavy breasts, such as neck and shoulder pain, irritation where the bra straps dig in, and rashes underneath the breasts (submammary intertrigo). In fact, when you can document medical problems related to your large breasts, you are much more likely to have your surgery covered by insurance.  According to the Anthem website, you’ll need to provide documentation that the surgery is medically necessary, that the appropriate amount of tissue will be removed and that there is a reasonable prognosis of symptomatic relief. Meet with one or more board-certified plastic surgeons who take your insurance. They should help you work with BCBS of CA to get pre-authorization. As far as the weight of your breasts, some research indicates that breasts as large as yours may weigh up to 8 pounds each. Of course, you will not lose this amount through your reduction. In answer to your third question, a qualified surgeon will be able to reduce your breasts to the size you want. Just be sure to communicate your expectations clearly, using photos or computer imaging if at all possible. Good luck!

Andrew Smith, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 24 reviews

Insurance Coverage

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Your insurance company is the best person to answer your question. 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.

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Will BCBS of CA PPO Cover my Breast Reduction? 34 G -34 H 0% Padded Bra.

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        If you have coverage in your policy, you can likely get approved.  Find a plastic surgeon with ELITE credentials who performs hundreds of breast reductions and breast lifts each year.  Then look at the plastic surgeon's website before and after photo galleries to get a sense of who can deliver the results.                                                                        Kenneth Hughes, MD Los Angeles, CA

You would qualify for insurance covered reduction

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and you just need to find a local participating plastic surgeon.  Not everyone participates so the list would allow you to call those that do.  Insurance usually requires failure of medical management so start working on that, whether its due to pains or rashes.  But simply by weight, you should easily qualify.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 33 reviews

Breast reduction coverage

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I think there is no question that your insurance should cover your breast reduction. The amount of tissue removed from each breast will easily exceed the minimum required by most insurance companies.  You should see a plastic surgeon who is part of your PPO network and start the preauthorization process.  I don't think they will give you any trouble, but sometimes the insurance companies can be difficult when it comes to authorizing breast reduction.  The key is to be persistent, and I'm sure you will get coverage.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 31 reviews

Breast Reduction San Diego (Photo)

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The photo is helpful, but each carrier has established written criteria for reduction mammaplasty to be a covered benefit.  Among these are disabling back, neck, and shoulder pain unresponsive to non-surgical measures.  Also, most carriers have published a minimum weight of reduction below which they will not pay for the procedure.  These minimum weights are supported by ZERO science.  In fact, the biomechanical benefit of the lift component of reduction mammaplasty provides as much or more relief as diminishing mass of the breasts, especially for women of short stature such as yourself.  That being said, even when I remove less than anticipated, I've never had an insurance company refuse to cover the procedure after it has been pre-authorized.  You should meet basic criteria for insurance to cover your reduction.  If they initially decline, appeal, and appeal again.  Insurance these days will do everything possible NOT to cover it.  If you cannot find a good surgeon in the network to do the procedure and accept insurance payment, strongly consider going to the surgeon of your choice and paying out of pocket.  It is usually worth the relief, improved breast size, shape, proportion, and more active lifestyle you'll get in return.

Steve Laverson, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 50 reviews

Breast Reduction and Insurance Coverage

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You look like an excellent candidate for breast reduction surgery. Most likely your insurance will cover the procedure unless your specific policy has an exclusion for breast reduction. You can call BCBS to check on your policy or see a Board Certified Plastic Surgeon that specializes in breast reduction surgery who will know how to help you submit for pre-authorization.

Most insurance companies require a minimum of 500 grams needed to be removed from each breast to qualify...that is usually a DD cup size. Next they will want to know what you have tried so far to alleviate your symptoms of discomfort that your large breasts cause. For example have you tried physical therapy? Special bras? Analgesics? Have documentation of anything you have tried that you can submit with your request for authorization. Lastly, if by chance you should be denied, ask your surgeon to appeal your case, I have done this many times for my patients getting the decision reversed. Good luck!

Miguel Delgado, MD
San Francisco Plastic Surgeon
4.8 out of 5 stars 81 reviews

Breast Reduction and Insurance Coverage?

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Thank you for the question and pictures.

Based on your description and pictures, you may be an excellent candidate for breast reduction surgery.  Unfortunately, there is no direct correlation between the amount of tissue removed and the specific cup size a patient will wear postoperatively; as you know, bra cup sizes will vary from one bra manufacturer to another.

Therefore, it is very important that patients communicate their goals carefully with their plastic surgeon prior to proceeding with surgery. In my practice, I prefer the use of goal pictures during this communication process.  Show your plastic surgeon examples of breast reduction “results” that you like, as well as breasts that are too large or too small.

Also, as you know, sometimes breast  reduction surgery is covered through health insurance. 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.
When the time is right, seek consultation with board-certified plastic surgeons to discuss your goals. Ask to see lots of examples of their work and communicate your goals carefully.  You may find the attached link helpful to you as you learn more about the procedure.
 If you decide to deal with health insurance companies, prepare to be persistent;  remember that breast reduction surgery is one of the most patient pleasing operations performed.
 Best wishes.

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.