Breast Reduction For JJ Cup With Federal Blue Cross Blue Shield PPO?

I've gone through two rounds of PT, anti-inflammation medication and muscle relaxers. My pcp bought up the idea of a breast reduction; however, I never followed up on her written referral. A year and a half later, the pain and shoulder grooving still exist and I have another referral. I have Federal BCBS PPO. I'm 240, 5'9, wear 36JJ and bottom heavy. My tummy is very flat and my waist fairly small. Even when I was 180, I still had the same cup size. Will my Insurance cover this?

Doctor Answers 7

Breast reduction coverage

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Patients with large breasts who also have persistent neck, back, and shoulder pain, shoulder grooving, and frequent rashes under the breasts tend to respond remarkably well to breast reduction.  In fact close to 90,000 women benefit from these procedure each year.  It can sometimes be challenging to prove medical necessity to an insurance company.  The more documentation you can get from your pcp and physical therapist the better.  The best judge as to whether you are a good candidate will be a local board certified plastic surgeon.

Yuba City Plastic Surgeon

Insurance coverage for breast reduction

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Not  surprisingly. Your insurance company wants to avoid paying for your breast reduction surgery if they can. They often give several excuses despite your symptoms.  Undergoing physical therapy is a waste of time.   They may deny coverage based on your weight even though the surgery will still be needed if you lose weight.   The key here is persistence.  The insurance company is hoping  you just give up trying. If you are indeed a good candidate for the surgery, you need to be persistent with the insurance company.  Eventually they may decide it is less of a  hassle  to  just approve the surgery than to field you calls on a daily basis.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 29 reviews

Insurance Covering Breast Reduction

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Sounds like you have covered most criteria that insurance companies require.In addition most will say a minimum of 500 grams of breast tissue needs to be removed from each breast and you would easily meet that. You should see a Board Certified Plastic Surgeon for an evaluation and to help you get pre-authorization. Insurance companies usually want documentation of what you have tried, such as a letter from your Physical Therapist and a letter from the doctor that prescribed your medications, but again your Plastic Surgeon will know how to submit your request. then it will depend if your insurance policy covers breast reduction or it may have an exclusion, but usually Federal insurance plans have good coverage. Good Luck!!

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

A strong likelihood for coverage by insurance plan for breast reduction

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From your explicit history, you stand an extremely high chance of being able to have insurance cover your breast reduction. You have failed conservative, non-operative therapy and hass massively enlarged breasts that would also qualify for coverage based on volume expected to be removed criteria.

You should consult with a board certified plastic surgeon in your area who can examine you, explain his/her recommendations and then obtain authorization from your insurance plan. Some weight loss prior to your procedure would also be helpful.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
4.7 out of 5 stars 33 reviews

You should definitely get insurance coverage for your breast reduction.

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Insurance Coverage for Breast Reduction.   I hope this article is useful.

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Insurance coverage for JJ cup

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Gigantomastia, with removal of over 1000 grams of tissue per breast, covered. You have had conservative management and it is a matter of your plastic surgeon submitting a detailed request for preauthorization to support the need for surgery. Best of luck.

Breast Reduction and insurance coverage.

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Thank you for the question.

Based on your description you may be a good candidate for breast reduction surgery; it may be in your best interest to drop weight first. The ideal situation is for you to lose  weight and be stable in regards to weight prior to surgery - that will give you the best chances of  long-term results  you will be happy with.  If you,  for example, have the surgery and then lose 20 more pounds, you may need to have another surgery because there may be additional loose skin to be removed  or you may be displeased with the ultimate breast size.

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 saying a well-trained/experienced board-certified plastic surgeon.  

I hope this helps.

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.