I am 5 ft 9 in, I weigh 140 lbs and my breast size is a 36 e. Would Horizon BCBS Cover BR?

I am 5 ft 9 in, I weigh 140 lbs and my breast size is a 36 e. I was trying to figure out the chances of horizon blue cross blue shield of nj covering a breast reduction surgery for me?

Doctor Answers 7

Insurance Coverage for Breast Reduction

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Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.

Best wishes,

Dr. Basu
Houston, TX

Insurance coverage for breast reduction

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It is very possible that your insurance will cover your breast reduction.  Each insurance company requests different information, you may want to call them,  An exam of course will be necessary.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

You will probably get insurance coverage for your breast reduction.

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I hope you find this article 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 prior approval for breast reduction surgery

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From your description you are a good candidate for breast reduction surgery.  There is no way to know in advance if you would be approved for the surgery until you are evaluated by a plastic surgeon.  At that time medical necessity can be established and you can begin the process of getting prior approval from your insurance company. 

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Breast reduction and insurance coverage

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Dear Olivia,


Based on your description you are likely a candidate for breast reduction. Your symptoms will need to be assessed and you need an examination by a board certified plastic surgeon. Once your plastic surgeon establishes medical necessity for you, he/she would act as a patient advocate to get authorization from your insurance company before the procedure. Do come in for a consultation and evaluation to explore your options. 

Kevin Tehrani, MD, FACS
New York Plastic Surgeon
4.7 out of 5 stars 106 reviews

Horizon BCBS coverage for breast reduction

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Horizon has very tricky criteria for breast reduction and, for personal experience, I must say that it stands out as a carrier which may approve a surgery in advance and then try not to pay afterwards so extreme caution is required. It requires detailed proof of conservative medical management. The best thing to do is to see a board certified plastic surgeon in NJ who has had a lot of experience dealing with this insurance company and can explain the criteria to you in detail. I would not recommend beginning to go through the hoops until all of the parameters have been explained. Best of luck.

Breast Reduction ad Insurance Coverage?

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Thank you for the question.

The best way to find out whether your insurance policy will potentially cover your breast reduction procedure is to call the insurance company directly. This way you will find out if the procedure is “covered” in your policy.

Obtaining 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 consulting with  well-trained/experienced board-certified plastic surgeon.
Also, prepare to be persistent. Ultimately it will likely be worth it; breast reduction is one of the most patient pleasing operations we perform.

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.