Tips and Chances of Getting Breast Reduction Approved by Insurance?

Insurance companies generally look at two factors in deciding whether or not to cover a breast reduction surgery:  1.  Functional problems.  You mentioned several already - back/neck pain and shoulder grooving and pain from bra straps.  2.  The amount of tissue to be removed - a breast reduction and a breast lift are essentially the same operation.  The only real difference is in the amount of tissue removed.  Insurance companies use various charts to determine if the amount of tissue estimated to be removed is enough to meet their requirements. This is usually based on your Body Surface Area which can be determined by your height and weight.  I looked up your BSA and determined that you would need to have about 440-480 grams of tissue removed in order to be covered.  Some insurance companies demand more than that.  I'm not sure off the top of my head what Blue Cross/Blue Shield requires.  Some insurance companies throw other obstacles in your path such as a requirement that you be examined by a chiropractor to determine that your issues aren't related to skeletal problems, a three month trial of anti-inflammatory agents to see if that helps your pain, etc.  At any rate, your examining plastic surgeon can help determine whether or not you will qualify for insurance coverage.

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

It sounds like you are aware of some of the insurance criteria, you are on the right track. The office of the surgeon you pick should be able to help you get approval. Be sure you find a Board Certified Plastic Surgeon and look for one who specializes in breast reduction surgery. They will be familiar with the ins and outs of pre-authorization. As you know different policies have different requirements, in general you should have some documentation of what you have already tried, such as physical therapy, analgesics, special bras, etc. Getting a letter from your internist or ob/gyn addressing these issues for your plastic surgeon will help speed up the process. Insurance companies are making it more difficult to get pre-authorization, if you do get turned down, ask your surgeon to make an appeal, then it will get reviewed by a medical doctor who will discuss your case with your surgeon. Our office has gotten approval many times this way! Good luck.

I can only comment on NY but in any event you should check with your insurance regarding requirements for elgibility because they are getting stricter and stricter.

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is 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.

Best wishes.

Wow, sounds like you have done a great deal of research already.  From your question it sounds like you are a candidate for breast reduction surgery.  I am a plastic surgeon in San Antonio, Texas not Florida, but the basics are the same.

First, I would suggest you call BCBS number on your card and make sure code 19318 is a covered benefit.  Then if it is ask for a copy of their coverage determination criteria.  Go through the criteria and make sure that you have satisfied many of the items.  Then select a Board Certified Plastic Surgeon in your area who has experience with Breast Reduction surgery.  If you have out of network benefits then you do not need to worry about whether the surgeon accepts BCBS or not.  In San Antonio, I have found many plastic surgeons are not participating with BCBS (I am) so you may only have a few to choose from.

Good luck!