Is it difficult to get approval for breast reduction from Tricare? Is it normal for Tricare to require a date before approving?

Question

I had my consult for a breast reduction. The doctors office submitted my request for a breast reduction. Tricare came back and said they required a date for the surgery. They didn't approve or disapprove the request. The doctors office then scheduled my surgery for June 30th and will resubmit to Tricare for approval. How likely is it that Tricare will approve my breast reduction. Is it a good sign that they didn't disapprove it?

Urmen Desai, MD, MPH, FACS · Answer

The fact that the insurance company is looking for a date is encouraging.  Make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS) and the American Society of Aesthetic Plastic Surgery (ASAPS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon

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

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
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Warren Schutte, MD · Answer

Thank you for your question.  If you meet the clinical guidelines with Tricare there is a good chance your surgery will be approved.  It is not uncommon for insurance companies to request a date of surgery for prior authorizations.  If they do approve your surgery and you cannot keep the authorized date, it will be important to have the office contact them to have the date of surgery updated.  Good luck!

Arian Mowlavi, MD, FACS (license on probation) · Answer

As long as you meet the criteria for breast reduction, you should have no problem getting your surgery approved.

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Unfortunately, dealing with insurance companies is often a challenging task. Your best option to see if your procedure is covered, is to contact your insurer to get details about coverage and requirements before approval for surgery (as you are doing). Given the difficulties of dealing with insurance, you can consider paying out of pocket for the surgery. For our patients, the out-of-pocket expenses for an insurance plan often approximate (or even exceed) the cost for the procedure. You can then obtain documentation from your surgeon to attempt to get reimbursement from your insurer. Any treatment plan should be based on a detailed discussion with equal input from both you and your surgeon.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   Preoperative visualization and surgical simulation with the Crisalix system may help with your decision. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation in person with a qualified board-certified plastic surgeon. Good luck! 
Best,
  
Jon Ver Halen, MD FACS 
  
Harvard educated plastic surgeon

Is it difficult to get approval for breast reduction from Tricare? Is it normal for Tricare to require a date before approving?

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