Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

Question

I have been treated for 3 months now for degenerative disc disease and spinal stenosis on my cervical spine, I have a lot of back pain, neck and left shoulder that radiates down to my fingers, I have seen my primary doctor, neurologist, spine specialist & physical therapy. Will this be sufficient for insurance to cover the breast procedure ?

Camille Cash, MD · Answer

There is a possibility that insurance will cover the breast reduction if certain criteria are met.  It will not cover a tummy tuck.  There are times when insurance covers a panniculectomy, which is different than a tummy tuck.  The best advice is to contact your insurance carrier directly to ask what the criteria are for coverage.

Kenneth Hughes, MD · Answer

Breast reductions with breast lift which are medically necessary i.e. you suffer back, shoulder, and neck pain with documented medical attention are typically covered by medical insurance. If not, your insurance company may try to deny you based upon a lot of things such as weight, causation of pain due to degenerative disc and spinal stenosis, lack of enough tissue that should be removed, lack of symptoms, and lack of previous medical management. The TT will be considered a cosmetic procedure and will not be covered.
Seek consultation with a board certified plastic surgeon who can evaluate your medical condition and assist you with obtaining a predetermination of benefits.
Kenneth Hughes, MD, Board Certified Plastic Surgeon
Los Angeles, CA

Praful Ramineni, MD · Answer

Given your symptoms, Blue Cross should cover your breast reduction (which lifts your breast at the same time), however the ultimate decision is based on how many grams are removed.  This is best discussed with your plastic surgeon.  The Tummy Tuck is unlikely to be covered for back problems.  A panniculectomy can sometimes be covered, however there is a laundry list of criteria that need to be met.  Basically you have to have wounds/open sores/infections under the hanging abdominal tissue that is documented for a period of time and has failed non-surgical therapy. Back pain is not a criteria for removal of abdominal tissue.

Vincent D. Lepore, MD (retired) · Answer

Although, most insurance companies do provide for coverage for breast reduction surgery (which also results in a breast lift), each company has their own criteria for coverage (amount of tissue to be removed and/or the size and weight of the breast, back/shoulder/neck pain, etc.).  From what you have described, you have seen the appropriate doctors to evaluate whether your pain is due to the weight of your breasts or other factors. Check with your plastic surgeon.  He/she should be able to help guide you through the approval process.  Unfortunately, insurance companies do not routinely cover tummy tuck procedures.  Best wishes, Dr. Lepore.

Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

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Answer: Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

Answer: Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

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Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

Answers (4)

Answer: Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

Answer: Will Blue Cross PPO cover for breast lift and reduction, tummy tuck due to back and neck pain problems?

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Everything you need to know about Mommy Makeover

Our mission is to create a world where every investment in modern beauty is Worth It.