Would BCBS of GA cover a breast reduction?

Question

I have severe spinal issues that I was born with. I have a "S" curvature of my spine due to scoliosis. Although I had corrective surgery (herrington rods placed) when I was younger, I was told I will have chronic lifelong pain in my neck, shoulders, and spine regardless of PT/medication because it couldnt be fully corrected. Now that I am older (28) and have two children, my breasts are at a DDD and the weight causes so much pain to my shoulders. do I have a good case?

Richard H. Tholen, MD, FACS · Answer

Your symptoms are certainly real, and you have correctly identified the reason--your scoliosis. Large breasts can also cause symptoms like you have described, even without scoliosis, which is why virtually all insurance companies have left subjective descriptions of pain, soreness, rashes, heaviness, etc. out of their decision-making process.As a former reviewer for Blue Cross/Blue Shield Insurance, and a reviewer for medicaid, I can tell you that the Schnur formula (based on BMI (height and weight) allow for insurance companies to use an objective set of criteria for breast reduction coverage. Most plastic surgeons have this formula memorized, and after examination of your breasts, can calculate the formula based on your height and weight, and tell you how much breast tissue must be removed per side in order to qualify for insurance coverage. There is a "minimum" removal of about one pound per breast, even if you are a tiny petite woman with proportionately large breasts, so this may result in near-mastectomies, depending on how you buy your bras, and if DDD fits well or not.The best advice I can give you is to go for one or more consultations with ABPS-certified plastic surgeons in your area and see how your anatomy fits the criteria. Many of my colleagues offer free consultations (as I do in my office), or the consultation may be billed to your insurance if you are trying for "coverage."Unfortunately, scoliosis does not necessarily "strengthen" your case for coverage--it will all be "cut and dried" based on your height, weight, and amount of tissue mandated for removal (assuming you have the subjective criteria list all plastic surgeons know.) Best wishes! Dr. Tholen

Carmen Kavali, MD · Answer

In many cases, yes, assuming you meet the criteria set by your insurance company within your specific policy.  You need to have a consultation with a plastic surgeon, and that office can help you with the whole process.  It's our job to make the process as simple as possible for you.Warmly,Dr. Kavali

C. Bob Basu, MD, MPH, FACS · Answer

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. BasuHouston, TX

Jeffrey Zwiren, MD · Answer

All insurance companies are different.  See a board certified plastic surgeon so that a letter of pre-determination of benefits can be sent to BCBS to determine you coverage.  Sounds like  you would be a good candidate.

Victor Urzola, MD · Answer

Dear patient,Thank you for your question.  Although I would prefer to see your pictures or have a personal consultation with you, from your medical history, it sounds like you are an excellent candidate for a breast reduction.  The  the best indication for this surgery is in patients who's breasts produce back problems and in your case I believe it would be on great help to alleviate the stress on your back.I hope this information was helpful.Best regards,Dr Urzola

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Would BCBS of GA cover a breast reduction?

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