BCBS Denied Me 2x for Breast Reduction? What Else Do They Need?

BCBS denied me, I appealed, they just denied me again. This time the reason is, "Your medical records fail to prove that this is the best treatment to stop your neck and shoulder pain." What are they needing now? I am getting so fustrated with them. I am 5"7 145lbs and I have 36DDD. If there is any info that could help me, that would be awesome!! Also, looking for a board certified p.s in the austin area that will help me get this done w/ insurance. The PS I saw in Temple wasn't helpful.

Doctor Answers 13

Getting Insurance Coverage for Breast Reduction

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Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company.  In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems..Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.

Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :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 though insurance criteria are becoming more and more restrictive.

Breast reduction surgery insurance approval

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Working on an appeal for this, you have to "know your enemy" with the specific carrier. By that, I mean research exactly what is required for documentation purposes and then create a paper trail to meet that list point by point. You can usually find policy manual requirements for your BCBS plan on Google.-You will need to have copies of prior doctor visit notes from your primary care doctor commenting on your symptoms and treatment-copies of any PT, ammasge therapy, or chiropractic care notes-copies of medications you've used for rashes and/or pain-a calculation of your body surface area (BSA) with the expected amount of tissue your doctor plans to remove. you can find bsa calculators online. Your policy manual will outline what kind of minimum weight removal may be required. It's usually at least 500 grams or uses a sliding scale (Schnur scale) based on your BSA
Even with all that, you may still find they won't cover it or possibly it's not even a part of your benefit manual with your BCBS plan


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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

Insurance Coverage for Breast Reduction

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If you are as big as you claim to be then a plastic surgeon should have little trouble convincing an ethical insurance company of the benefits of breast reduction. Generally patients who have all or part of their surgery covered have chronic back, neck, and/or shoulder pain. They may have exercise intolerance as well. Physical exam could exam could show shoulder grooves, and even scarring or variations in pigmentation. A history of pain related problems helps but it is not always necessary. It always amazes me that some stupid insurance company administrator recommends x-rays, MRI, pain medication, and physical therapy, all of which is a waste of money. If they deny after that, i have told the edical director that I have referred the pateint to himas he obviously knows how to reduce the symptoms that no one else does. That usually generally does it.

Insurance coverage for Breast Reduction surgery

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Documentation, documentation, documentation! It is often helpful to have as many specialists recommend in writing your surgery, ie; pain specialist, orthopedist, spine surgeon, primary Dr., OB-Gyn, etc. The more the better! Even if you have these, you may still get denied. Do yourself a favor and call your carrier directly and find out how many grams are required to be removed for coverage. You may not be happy to hear that the amount they require may leave you too small. If this is the case, then I strongly suggest you finance it yourself. If this is a feasible option, look into the Ultimate Breast Lift/Reduction. There is no vertical scar regardless of how large or saggy. Weight of breast is transferred off your skin and on to your chest muscles for instant relief of neck and shoulders caused by large/pendulous breasts.

Hope this helps.

Kind regards,

Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Second denial for breast reduction

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Ok. They want proof that the reduction will alleviate th back and shoulder pain. While we know that breast reduction will accomplish this, what they are saying indirectly is to find a cheaper, non-invasive way first and then show us that it didn't work. Check the BC website for your carrier and find criteria for coverage on line. Try may require 6 months of chiropractic or physical therapy. Fulfill this requirement per the guidelines and then reapply for preauthorization. The second level denial in many states must. Ewritten by a board certified physician in the specialty so make sure the insurer played fair and didn't have pediatrician review your request.

Insurancena nd breast reductions

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Welcome to the world of medical insurance!  Jumping through hoops is part of their game.,e venthough you may be a very good candidate for surgery.  When all else fails, you may wnat to consider self-paying.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Insurance coverage for breast reduction

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Each insurance company has different criteria that it uses to determine medical necessity. Your plastic surgeon may be able to get these criteria which you can then use to document your need. In addition, policies even with the same insurance company can vary. So it may take a bit to determine what criteria you need to meet. This can be very frustrating but just be aware that this is fairly standard procedure for insurance authorizations; most, if not all, of us who do breast reduction surgery have experienced it with our patients. Be persistent and good luck to you.

Margaret Skiles, MD (retired)
Sacramento Plastic Surgeon


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Didn't their initials give you a hint?  BS  BS  BS  BS

You are wasting your time and the time of any surgeon that trys to help you in this hopeless endevour. Insurance companies have been allowed to defraud their cusomers and that means you. You need to save your pennies until you have $7,172 (the total cost for breast reduction at Lake Tahoe Plastic Surgery) use a credit card or apply for credit with Care Credit or Chase Health Advance. We help patients if they want to avoid the 10% surcharge of the finance companies by acting as their savings bank. You can send us $100/month and in less than a year and a half you'll be able to have your procedure. Some patients might have a family emergency come up before they've reached the grand total. We then give them back the entire amount they've submitted so they can start over when the personal problem is resolved.  


Dr Foster 

Lawrence Foster, MD (retired)
Sacramento Plastic Surgeon

BCBS Denied Me

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They look for things like weight loss (not an issue for you) and a reasonable time trying nonsurgical methods of back and neck pain relief. Often notes from a physical therapist, orthopedist or chiropractor will help. Then have your plastic surgeon send in a not with estimates of the breast weight he expects to remove.This is a stalling technique all insurance companies use to try and avoid payhing out claims. They hope you will go away. Have an attorney write a letter and tell Blue Cross he wants to know the specifics of their denial and exactly what else they want. Sometimes that will light a fire under them.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 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.