Does GEHA Cover Breast Reduction?

Question

I'm a 46 yr old 5'0" female weighing 116 lbs. I'm a 36DD and would like to reduce to a 36B. I've experienced all the symptoms; chronic back pain, neck and shoulder pain, bad posture ect. due to my large breasts. I have medical insurance with GEHA and was wondering if they cover the procedure & what their pre-requisites are. Poor body image & high cost have precluded me from seeking medical advice for this issue in the past. Also, I am a pack a day smoker so is this even an option for me?

Leo Lapuerta, MD · Answer

You can check with your insurance company if they cover breast reductions. An in surance company has certain prerequisites for coverage. They want your height and weight, pictures, and documentation ofr back troubles with results of x-rays and treatment dates. They may also ask for two letters from docors and copies of physical therapy etc. They make it very difficult and try to reject preauthorizations. A patient and their doctor then goes through an appeal process. This takes months. Some patients just pay for the surgey themselves if insurance does not cover it. Some companies have dropped it from their plans. They are not our friends.

	Smoking increases your chances of complications and decreases blood flow to the skin and nipple. Smokers can have severe complications such as nipple loss, tissue loss, and infections.

	Breast reduction patients are some of the happiest patients in my practice and I encourage you to quit smoking and have the procedure done.

	 

	Leo Lapuerta MD

Steven Turkeltaub, MD · Answer

You need to first determine whether breast reduction is a covered procedure under your insurance policy. If it is, you should schedule a consultation with a board certified plastic surgeon in your area who can do a full assessment and then submit the information to GEHA. Supporting documentation is needed including information that falls within their coverage criteria.

	Good luck!

Darryl J. Blinski, MD · Answer

Best to see in person a boarded PS in your area. He/she can examine, photograph you. Than write a letter vto your insurance company as a predetermination of benefits. The smoking is an issue of concern.

Tom J. Pousti, MD · Answer

Every insurance company has different policy and requirements for breast reduction coverage. These requirements seem to be getting more strict as time goes by. You would need to check with your insurance company regarding your specific policy.

	You should also stop smoking prior to surgery; I asked patients to stop any form of nicotine use one month prior to surgery. I think that you will find that the benefits you will gain from the breast reduction surgery will be worth it.

	Best wishes.

George J. Beraka, MD (retired) · Answer

Insurance Coverage for Breast Reduction
	Article by George J. Beraka, MD
	Manhattan Plastic Surgeon

	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.

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