Does Humana insurance cover breast reduction?

Question

Yes I have been trying for years to get a breast reduction and it is needed my breast are to heavy I have indentations where my bra straps sit as well as back pain I'm doing what is required but still hitting a brick wall I saw a surgeon who told me that he would it as cosmetic surgery instead of medically needed and I wanna know what is my best option for getting this resolved because I don't want to give up on this

Gary M. Horndeski, MD · Answer

Thank you for you question,         The Bellesoma Method is a current technique to lift and/or reduce breasts without using implants or the ugly vertical scars.  The incisions are hidden around the areola and in the inframammary crease. The vertical incision has been completely eliminated. The areola incision heals almost invisibly due to the fact that there is hardly any tension on the closure. With this particular technique, ducts are preserved along with nerve supply maintaining nipple sensation and the ability to breast feed. Because the breast is reshaped internally and is secured to your chest muscles, upper pole fullness is possible without an implant. Attached is a patient who underwent The Bellesoma Method. Please note that her tissue was used to create upper pole fullness and cleavage without any foreign materials (mesh, implants, etc).  Unfortunately, we do not accept insurance for breast reductions.  Dr. Horndeski does not remove enough breast tissue to meet insurance criteria.  Instead, he utilizes the breast tissue to reshape the breast.  It is a proprietary technique that only surgeons that have been trained by me can perform. I hope this helps. Best wishes and kind regards, Dr. Gary Horndeski

Larry S. Nichter, MD, MS, FACS · Answer

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

John Michael Thomassen, MD · Answer

Most insurances do cover this procedure but you should have a minimum amount of grams of tissue removed to qualify.  Usually around 500 gm minimum.  Also, some insurance plans carve out this type of coverage so it depends on the plan you acquired.  You could always do it self pay which will be in the order of $5k.

Daniel Barrett, MD · Answer

Dear Deelovely37,Many women have overdevelopment of breast tissue and require reductions.  Some of the questions you need to ask yourself are if you are willing to have scars from the surgery, take the risk of losing nipple sensation and other complications in addition to possible problems breast feeding if you plan to have children in the future. I would meet with another plastic surgeon to go over all of these risks and benefits to see if you would be a good candidate for surgery.Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

Joel M. Stewart, Jr., MD · Answer

The answer depends on the particular policy you have. You can call the insurance company, give them your policy number, and they will be able to tell you if it is covered and what is required for coverage. They are supposed to help you with such matters.
Then, you need to see a Board Certified Plastic Surgeon and have an evaluation. Insurance companies have certain symptoms that must be documented and require that a certain weight of breast tissue be removed in most cases.
Your surgeon can then evaluate you and submit the necessary paperwork.
Hope this helps.

Reza Momeni, MD, FACS · Answer

Breast reduction eligibility and coverage by insurance varies from one insurance carrier to the next, and cannot be determined based on cup size, but only based on an in-person examination to figure out how much tissue the surgeon needs to remove.  You also often have to qualify for multiple other criteria from your insurance carrier, so be sure to request their breast reduction coverage policy ahead of time before your plastic surgery visit to ensure you meet all the other non-size related demands that they have.  Be sure to discuss your goals and concerns with your board certified plastic surgeon and consider the pros and the cons. Be certain your surgeon is properly certified.  I've attached a link where you can start your search.

Kris M. Reddy, MD, FACS · Answer

Insurance coverage is getting increasingly difficult. To understand your insurance company's requirements, you should first contact the insurance company. Typically, you will need to contact your primary physician to have him/her evaluate and determine if he/she feels that the surgery is medically necessary. If so, they should write a letter of medical necessity. Frequently, the primary physician will need to have you try other methods to address the functional complaints for a period of time (defined by the insurance company). You will then consult a board certified plastic surgeon (who is who needs to determine if you are a candidate for the procedure and the amount of breast tissue that needs to be removed. The surgical plan will need to meet the requirements of your insurance company. The probability of coverage is declining and most board certified plastic surgeons will require payment beforehand and help with the patient receive reimbursement from the insurance company.

Vinod V. Pathy, MD, FACS · Answer

Thanks for your question. The short answer is, "Maybe". Most insurance carriers have specific criteria a patient must meet or fulfill prior to them covering a breast reduction. These may include documentation of pain, rashes beneath the breasts when present, bra strap grooving, and failure of more conservative measures to alleviate pain (ie. physical therapy, chiropractic care, etc.). I would suggest you call your insurance carrier directly to discuss what your particular plan requires prior to approval. A board certified plastic surgeon can also help to guide you through this process, so it might be beneficial to you to seek consultation and get the ball rolling. Best of luck!

Darryl J. Blinski, MD · Answer

The issue is two fold. 1st does the Humana Health plan offer restrictions to breast reduction surgeries. Each plan has their own restrictions or non covered benefits. If there s potential her;th benefits than the criteria might be very restrictive, i.e. ht vs wt, prior non invasive regimes to alleviate your medical symptoms. 2nd are you really a candidate for reconstructive breasts reduction surgery? You wrote a PS saw/examied you and felt you were a cosmetic breast reduction candidate. Now there is a paper trail which might cause the insurance company to not approve your surgery. BTW you did not post pics so we as responding boarded MDs can not offer a RS over the internet opinion.

Praful Ramineni, MD · Answer

Humana does cover Breast reduction, however the criteria will require a certain number of grams to be removed.  It may be that your surgeon does not feel that you have enough breast tissue to meet insurance criteria while achieving a good aesthetic outcome/meet your goals.  You can always consult with another plastic surgeon in your area to see if they agree.

Does Humana insurance cover breast reduction?

Answers (11)

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