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What Do I Need to Do for BCBS of NJ PPO to Cover my Breast Reduction?

I am 29 and 5"3 and weigh 140 lbs. I push out of a 34dd and would like to go down to a 34 full b/c. I have gone through two pregnancies/nursing and am now done. I have waited the 7 mo post nursing and have lost all the weight and then some. I have BCBS of NJ ppo and would like them to cover surgery as I cannot alone. I have documented with past ob/gyns the neck/back pain and headaches. Any words of advice to make this go smoothly with insurance. (live in NV with surgeons in ntwrk)

Doctor Answers 14

October 6th, 2010

Insurance coverage for Breast Reduction

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If you have documented symptoms of back pain, neck pain, shoulder pain related to large breasts, insurance may cover your breast reduction. You need to see a plastic surgeon who is on your insurance plan for maximum benefit. During your consultation and exam, your doctor will let you know whether or not you are good candidate to have this done and be covered by insurance. A preauthorization from your insurance company, however, is no guarantee of payment, so be prepared for some financial obligation.

Hayley Brown, MD, FACS
August 2nd, 2014

Insurance coverage of breast reduction?

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Hello! Thank you for your question! Surgical procedures for aesthetic purposes, to improve appearance, are not covered by insurance. Typically, these as well as complications resulting from such procedures are the responsibility of the patient. Procedures that are meant to correct functional issues and those which cause health-related issues should be covered by your insurance as a medical necessity, with proper examination and documentation. Some insurance plans have exclusion criteria for certain procedures. Also, it is an obligation of the surgeon not to attempt to authorize purely cosmetic procedures through insurance.

Discuss your issues and complaints with a board-certified plastic surgeon to discuss these as well as to examine and assist you in deciding which procedure(s) will be the best for you.  Typically a description of your complaints as well as a detailed examination, measurements, estimate of weight removed, and photographs will be required.  A discussion of the advantages and disadvantages will take place along with the risks and benefits. Insurance companies will vary on coverage and is always reasonable to discuss your issues with your surgeon and primary care. It would behoove you to get as much information as possible and even call your insurance yourself. Certainly, pay in advance prior to your surgical procedure and options such as financing are available if you qualify. Hope that this helps! Best wishes!
Lewis Albert Andres, MD
June 8th, 2014

Insurance

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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
C. Bob Basu, MD, FACS
June 13th, 2013

Insurance coverage for Breast Reduction

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Insurance coverage is a fickle thing.  The only way to know for sure is to be evaluated by a plastic surgeon.  At this time a pre-approval letter will be sent.  The insurance company reviews the information and magically make a medical decision whether or not they intend to cover the procedure.  It is not always a fair or just decision.  From your description you seem to be a good candidate for the operation and would get symptomatic relief from your large breasts.

Jeffrey Zwiren, MD
September 17th, 2011

Breast reduction insurance coverage

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Based on your description you may be a good candidate for breast reduction surgery; for  physical and emotional reasons.
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. Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.
Good luck!

Learn more: http://www.poustiplasticsurgery.com/Procedures/procedure_breastreduction.htm

Tom J. Pousti, MD, FACS
May 1st, 2011

Breast reduction

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Horizon blue cross of new jersey is the most difficult plan to get authorization. You will need letters from two other physicians including an evaluation for back pain. Also notes from six months of conservative treatment like physical therapy.

David L. Abramson, MD
New York Plastic Surgeon

December 12th, 2010

Breast reduction insurance coverage

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Your best bet is to find a participating surgeon and go in for a consultation and have a predetermination of benefits letter composed to ascertain your level of coverage.

Learn more: http://www.bodysculptor.com/breast-surgery-chicago/breast-reduction/

Otto Joseph Placik, MD
October 15th, 2010

Breast reduction insurance coverage

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Breast reduction for large breasts is usually covered by insurance when the surgery is performed as part of a medically mandated procedure to treat neck, back, or shoulder pain or other problems related to the spine. Recently, managed care has adopted stricter standards for coverage, so these problems have to be thoroughly documented in writing by your primary care physician and plastic surgeon. They may also have to submit photographs. Even then, you may be required to seek a second opinion from a chiropractor, physical therapist, or orthopedic surgeon.

Michelle Copeland, MD, DMD
October 13th, 2010

Breast reduction and insurance "coverage"

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I recommend a different approach. Rather than depend on a government regulated insurance company or the government to "cover" you for a breast reduction procedure and determine whether you can have it, who you can go to, how much breast has to be removed, and what they will pay the surgeon and facility, I would think of it as a cosmetic procedure that you can choose all these things for yourself. It is possible to do breast reduction surgery under local anesthesia with IV sedation in an accredited office setting and thus keep costs down. You would also know exactly what is to be done and how much that will cost. This requires finding a surgeon who can handle any and all breast procedures (aside from major breast reconstruction) as if they were cosmetic rather than functional. This is a bit like having to pay taxes for public schools but choosing to send your children to a private school where you get what you want but have to pay for it yourself. As the federal government continues to take over health care decisions and engages in wage and price controls, this will be an increasingly common approach to getting the procedures and care you want and feel you need. 

Scott L. Replogle, MD
Boulder Plastic Surgeon

October 6th, 2010

Insurence coverage for breast reduction

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You need to establish medical necessity as defined by your plan.  Your plan should be able to give you there criteria.  Some guidelines are you need to be near normal body weight,  symptoms of back, neck ,and shoulder pain that is not relieved with 6-9 months of therapy ( documented by an orthopedic surgeon or rehab doc ).  Make sure your plan does not exclude this procedure.  Good Luck

Robert D. Goldstein, MD
Bronx Plastic Surgeon

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.