Will BCBS (Federal) cover my breast reduction?

Question

Hi! I am 19 years old, about 5'4 and 125 pounds. My bra size is a 32F and I am really interested in getting a breast reduction. I have a lot of back / neck pain and I cannot sleep on my back at night because the weight of my breasts makes it hard to breathe. Unfortunately I don't have documentation of the pain because as a young person (and the child of a single mom who already has enough debt) I have just had a "grin and bear it" attitude about the situation. Is my size alone enough for coverage?

Emmanuel Mallol Cotes, MD · Answer

Thanks for sharing your concerns with us. Usually insurance doesntcover plastic surgeries but i have an excellent option for you. The Dominican Republic is a beautiful  country, located an hour and a half from the United States, in the middle of the Caribbean sea. Its excellent weather and its political and economic stability, as a remarkable development in many areas, including medicine and professional training in plastic surgery (highly specialized in places like Brazil, United States and Europe) have made an excellent and safe destination for health tourism, in special for the Plastic Surgery, which it is already a global reference.I advise you to make direct contact with a board certified plastic, aesthetic and reconstructive surgeons in the Dominican Republic, and you should develop a fluid communication between you and this plastic surgeon, who will answer all your questions about the surgery that you interested, his academic training, experience, medical center where he works, and pos operatory recovery.I also advise you to search on it on the Internet and visit his website.Respectfully,Dr. Emmanuel Mallol Cotes.-

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Every insurance company is different. You will have to specifically ask them what their criteria is forcoverage of a breast reduction. It may be size only or other factors that determine coverage.

David J. Wages, MD · Answer

Thank you for your question.  Generally speaking if a woman has large breasts that
are affecting her quality of life it is enough to open the door for discussion.
 What you describe is certainly concerning and I would welcome a patient
with your description for a face to face consultation.  During this visit
the physician should obtain a comprehensive history and perform a physical
exam.  After completing this it should be clear what can be achieved with
surgery or if there are any non-surgical options.  In my practice age is a
concern but by no means should it prevent the discussion.  If you are a
candidate for surgery then when the patient is ready we move forward.
 Many insurances cover this but depending upon the carrier there are
discrepancies about the amounts needed to be removed to qualify (something your
surgeon will have to estimate).  Always seek a Board Certified
Plastic Surgeon who has experience with breast reduction.  See plenty of
before and afters and do your homework.  Good luck.

Sugene Kim, MD, FACS · Answer

Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Please check your insurance policy to see whether breast reduction is a covered procedure. Often times, insurance company will dictate how much breast tissue to be removed. Please visit an experiences, board-certified plastic surgeon to learn about the procedure, its cons and pros, benefits, and alternatives. Please contact your insurance carrier to learn about inclusion and exclusion criteria. Best wishes.

Tom J. Pousti, MD · Answer

Thank you for the question. Based on your description, it sounds like you may be an excellent candidate for  breast reduction surgery; of course, much more information is necessary to provide you with definitive advice

Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals that breast reduction surgery is one of the most patient pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link, helps. Best wishes.

Steven Wallach, MD · Answer

Each insurance company has different criteria for approval of breast reductions surgery. You should contact your carrier and find out their criteria first. Good luck.

Robert L. Kraft, MD, FACS · Answer

First, BCBS has historically been easier to deal with than other carriers.  That said, size alone is not the only consideration.  Take a look at the BCBS website which will explain the additional requirements with respect to conservative medical management.  You will need to complete a course of physical therapy or chiropractic with full documentation.  Some plans have precertification. If BCFEP does not, do not be fooled into complacency as they can deny a case after the fact which would leave you with bills that are much higher than negotiated cosmetic ones. It is very important to do the homework and make sure the procedure will be covered at the end of the day.

Will BCBS (Federal) cover my breast reduction?

Answers (7)

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