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

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

Walter D. Gracia, MD · Answer

In the past 4-6 months the amount of paperwork required to get insurance approval for a breast reduction went from a lot to enormous and they still deny them with the extra information. In addition to the weight and height and the estimated reduction based on the Schnur paper they require preop mammograms for relatively young patients and neck x-rays and documentation of PT or Chiropractic intervention preop.The extra info is used more to deny care than approve it. It is not clear if a plan neck x-ray is needed or a CT or MRI.

Wesley T. Myers, MD · Answer

Women who have
large breasts may experience a variety of problems from the weight and size of
their breasts, such as back, neck and shoulder pain and skin irritation. Many
women who suffer from back pain due to the size of their breast find that the
pain is unrelieved by over the counter medications, support garments, bras, and
physical therapy. Some women even develop significant arthritic changes in
their neck and upper back. They often find that their persistent symptoms cause
a significant restriction of daily activities. Occasionally, women with large
breast, suffer from non-seasonal rashes underneath their breast that are
unresponsive to local hygiene and topical creams and powders. Women with large
breast may notice shoulder grooving with skin irritation due to their bra
straps and support garments. They may also notice pain and numbness in their
arms and hands. Breast reduction is usually performed for relief of these
symptoms rather than to enhance the appearance of the breasts. Breast reduction
surgery removes excess breast fat, glandular tissue and skin to achieve a
breast size in proportion with your body and to alleviate the discomfort
associated with overly large breasts. The best candidates are those who are
mature enough to understand the procedure and have realistic expectations about
the results. There are a variety of different surgical techniques used to
reduce and reshape the female breast. I recommend that you make an appointment
with a board certified plastic surgeon to discuss your surgical options.

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.

Erel Laufer, MD · Answer

Most insurance companies will cover the reduction of symptomatic oversized breasts provided you fall within the norms of BMI and that you have a letter of support from your treating physicians.

Ronald V. DeMars, MD (Retired) · Answer

It sounds like you should easily meet BCBS criteria, but you'll never know for sure until you see a consultant and the doctor then requests preapproval of coverage from the insurance company.

BCBS TX covering my breast reduction?

Answers (9)

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