Breast Reduction with insurance BCBS Federal. Is 500 grams too much?

Question

I’ve had rotator cuff surgery on both shoulders with one being unsuccessful/irreparable. Over the past couple of years wearing any type of bra is causing serious pain- primary doctor recommended a Breast Reduction. I ‘m a 38 D, med. frame-5'8”, 155 lbs, 57yrs with dense breasts. BCBS should cover the procedure but requires 500g+ per breast be removed. For pain I’d like to go as small/light as possible for my build (B cup?) Is 500g too much to achieve this and still look proportional?

Scott C. Lindsay, DO · Answer

Hello and thank you for your question.
It is difficult to answer you question with out photos.  Schedule a consultation with a board certified plastic surgeon to discuss your options. Best of luck!

Kenneth Hughes, MD · Answer

None of us can predict what decisions insurance companies will make regarding coverage for BR surgery or what documentation will sway their decision. BRs which are medically necessary (i.e. you suffer back, shoulder, and neck "pain" with DOCUMENTED medical attention over a period of a YEAR) are typically covered by medical insurance.  If not, your medical insurance may try to deny you based upon a lot of things such as weight, lack of symptoms, lack of previous medical management, and lack of enough tissue that should be removed. 
Read your BCBS Federal medical insurance certificate of coverage. Determine what medical information is required for BCBS Federal to issue a pre-authorization or predetermination of benefits for BR surgery. Then seek consultation with a board certified plastic surgeon who can evaluate your medical condition, discuss the pros and cons of this surgery as it applies to you, determine the amount of tissue to be removed, and help you in completing the paperwork required by your medical insurance company.  (Take all documentation you have accumulated from your PCP to your board certified PS's consultation appointment.)

Gary M. Horndeski, MD · Answer

At size 38 D, each 200 grams removed corresponds to 1 cup size change.  If you removed 500 grams, that would take you down 2 1/2 cup sizes to between an A and B, which may be too small for you.  The technique I recommend is The Bellesoma Method.  This will reduce and reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage.  The weight of the breast is transferred to the underlying pectoralis major muscle resulting in pain relief without excessive reduction.  Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained.  This technique is not covered by insurance since you will not need or desire to remove 500 grams.Best Wishes,Gary Horndeski, M.D.

Miguel Delgado, MD · Answer

Most insurance companies require a minimum of 500 grams needs to be removed in order for insurance to cover. Without pictures it is hard to give an opinion. Your best bet is to consult with a board certified plastic surgeon who will be able to discuss all your options. Good luck.

Donovan Rosas, MD · Answer

When considering breast reduction, in addition to establishing a case for medical necessity, there are also requirements for resection weight (when covered by insurance). This may be a standard "500 gm per side" stipulation or a more variable standard based upon body surface area/Schnur scale. It is important to realize that these weight requirements can occasionally exceed your goals for size reduction. Insurance coverage is contingent on these requirements being met, thus cosmetic concerns become secondary(i.e. cup size goals).
With regards to your specific question, there are reduction limits which are independent of insurance requirements. A certain amount of tissue must be maintained in order to preserve the vascularity to the nipple areolar complex. The larger and more ptotic the breast, the more difficult it is to reach a significantly smaller size post op (a full B from a D is not unrealistic).
As always, discuss your concerns with a board certified plastic surgeon (ABPS).
Donovan Rosas MD
Board Certified by the American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons
RealSelf Top 100
RealSelf Hall of Fame

Breast Reduction with insurance BCBS Federal. Is 500 grams too much?

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Breast Reduction with insurance BCBS Federal. Is 500 grams too much?

Answers (9)

Answer: 500 Grams Too Much for Breast Reduction?

Answer: 500 Grams Too Much for Breast Reduction?

Answer: Is 500 gms too much?

Answer: Is 500 gms too much?

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Everything you need to know about Breast Reduction

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