BCBS TX covering my breast reduction?

Question

I'm 23, 5'6 and weigh 159. I wear a size 32G or a 32DDDD and I was wondering if my chances were good for getting covered for a breast reduction by BCBS Tx? I did see a chiropractor for a few months to get my back readjusted as I had been experiencing pain between my shoulder blades. After stopping my visits, the pain still persists. I'm hoping to meet with a surgeon, but I'm not sure if my chances are any good.

J. Jason Wendel, MD, FACS · Answer

Thank you for your question.Yes, it is possible that you might qualify for insurance breast reduction, but you need to have a consultation to find out.

To see if you might qualify, see two or more experienced,
board-certified Plastic Surgeons for a complete evaluation to make sure you are
a good candidate and that it is safe for you to have surgery.

I hope this helps.

Richard H. Tholen, MD, FACS · Answer

By the Schnur formula that many insurance providers use, your height and weight (BMI) would require a minimum of 467g per breast be removed in order to receive coverage. This is, of course, in addition to all of the other requirements of your specific insurer being met, often including a minimum period of physical therapy, X-rays or scans, and other requirements designed to deny coverage. (BTW, when they deny coverage, they try to make it sound as if your surgeon did not do something right, like supply the correct information or fill out the required form.)You should see one or more ABPS-certified plastic surgeons in your area for examination, measurements, and verification of height, weight, and computation of the minimum resection required for coverage.Then, ask your surgeon to show you a breast implant near that size (454g = 1 pound), and try to visualize what breast tissue remains after removal of that amount from each side. Based on your bra size, you may very well qualify, but if you and your surgeon feel that removal of 468+ grams per side (or whatever your exact BMI requires) leaves you too small, then you would be wise to ask for elective self-pay breast lift or cosmetic reduction that does not require specific amounts of tissue removal that could leave you "too small."Nothing worse than having more than enough breast tissue in the first place, and then needing implants later to replace the "too much" that was removed to obtain reimbursement! Best wishes! Dr. Tholen

Tom J. Pousti, MD · Answer

Based on your description you may be an excellent candidate for breast reduction surgery; this operation tends to be one of the most patient pleasing operations we perform.

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 are working with a well-trained/experienced board-certified plastic surgeon.
Good luck;  prepare to be persistent when dealing with health insurance companies.

Josef Hadeed, MD, FACS · Answer

There are several criteria that must be met in order to get insurance to cover a breast reduction.  A consultation with a board certified plastic surgeon can help you understand what your options are.

Craig Harrison, MD · Answer

By your history and numbers you might qualify for coverage. I suggest that you read your policy( or check with your HR people at work) and be certain that breast reduction surgery isn't excluded in your policy. If it isn't excluded then arrange a consultation with a plastic surgeon in your network.  After further evaluation, a predetermination letter accompanied with photos to BC/ BS would answer the question.Best wishes

BCBS TX covering my breast reduction?

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BCBS TX covering my breast reduction?

Answers (9)

Answer: Insurance coverage breast reduction

Answer: Insurance coverage breast reduction

Answer: Insurance coverage for breast reduction

Answer: Insurance coverage for breast reduction

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Recommended reading

Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.