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

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.

Every insurance company is different depending on the plans that you have. In general, insurance companies want you to have documented that you have had back pain for some time. Then they want you to have tried conservative treatment (therapy, chiropractor, and pain medications.) Then based on your height and weight, they determine how much breast tissue has to be taken off to cover the procedure. Consult with a board certified plastic surgeon, they will help you through the process.

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!

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.

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 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.

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!

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.

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.

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