Will TennCare approve my breast reduction? (Photo)

Question

I am 18 yrs. old 5'2 and 130lbs. but my breast a very large. I have had big breast since the 5th grade and had trouble breathing, bending and doing most daily activities. I recently good a job at a grocery store and I can barely do my job without pains or breathing problems. I was wondering will TennCare help pay for it. I have been longing for one for so long but never thought I'd get approved. (The picture is from three years ago. I was 15yrs. old)

Jed H. Horowitz, MD, FACS · Answer

From your picture, you do appear to be a good candidate for breast reduction surgery. The symptoms you are experiencing are quite common. Many can include back, neck and shoulder pain, shortness of breath and difficulty completing normal activities. 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. However, any company or insurance provider in Tennessee has to only follow the requirements set by the state. This TN code only covers breast reconstruction after a mastectomy and surgery to correct asymetric breasts (breasts that are two different sizes). It would still be helpful for you to speak with someone from TennCare. #plastic surgery #breast reduction #insurance coverage #TennCare

Larry S. Nichter, MD, MS, FACS · Answer

From your description it seems as if you are a good candidate for breast reduction. 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. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Sheila S. Nazarian, MD · Answer

First, you need to call your insurance company and see if they cover breast reduction surgery. Then, ask them exactly what criteria you would need to meet. Last, schedule a consultation with a board certified plastic surgeon in your area (link below) to discuss. Best, Dr. Nazarian

Darryl J. Blinski, MD · Answer

We can not respond if your health insurance would cover the reduction surgery. Best to call or write to them for predetermination of benefits......

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

Alan M. Engler, MD, FACS (retired) · Answer

You'll have to meet with one or more plastic surgeons who can examine you in person, and who is familiar with the standards of TennCare, to get an answer to this.Each insurance company has its own criteria, and what were valid a few years ago (in that regard) may no longer be today.  Considerations typically include your height, weight, bra size, BMI, symptoms, etc.  Taking all of those together, the insurance company will typically decide whether or not the procedure is indicated and, if so, how much tissue would need to be removed.All of which you'll need to discuss with your own PS.I hope that this helps and good luck,Dr. Alan EnglerMember of #RealSelf100

Will TennCare approve my breast reduction? (Photo)

Answers (6)

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