What's the Chance of BCBS of MI Approving Me POST-OP? (photo)

I am 5'4 about 207lbs w/ 36H and was referred by my OBGYN in Jul to my PS for a BR. At my consultation last Friday, the PS said w/ a small frame and with the some of the symptoms I have had (neck/back pain, deep indents frm bra straps, bad posture) def. thinks I would benefit from a BR. Also said they are very heavy and made it hard for him to measure even.He's thinking he will remove 800-900grms to get me to C/D. BCBS said they don't do PAs for BRs. What are my chances of being aprvd post-op?

Doctor Answers 5

Insurance coverage

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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. Basu
Houston, TX

Postauth for breast reduction

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Some BC plans do not preauthorize surgeries. If so, you do risk a postop denial. Check your insurance criteria online to see if you will qualify. BC often wants proof of conservative management and, despite the amount of the reduction, unless you qualify as gigantomastia, I would be cautious about assuming that you will be reimbursed.

Predetermination is best before breast reduction

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We are not in Michigan, though nearby in Illinois we always complete a predetermination with Blue Cross to find out if breast reduction is a benefit, and under what circumstances. This differs from a pre authorization which as you know Blue Cross will no longer do.The more you know before you commit the better for all.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Breast Reduction and Insurance Coverage?

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Unfortunately, there is no way of predicting what the likelihood of postoperative approval for the breast reduction procedure will be in your case.  Your best bet will be to communicate with the insurance company (in writing preferably) and obtain as much support as possible ( primary care physician, plastic surgeon…) For the need for breast reduction ( prior to undergoing the procedure).

Ultimately,  you may not have 100% assurance or peace of mind that the procedure will be covered. You will have to make a decision whether (based on the specifics in your situation) the risk is worth taking.

Keep in mind, that you may do better ( with the safety of the procedure and avoidance of the need for further surgery)  if you achieve a long-term stable weight ( if you are not there already) prior to undergoing the  breast reduction procedure.

 I hope this helps.

PS to do BR, but need PA for BCBS to PAY

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BCBS in some states have "streamlined" pre-determinations for plastic surgery. It is a one page fill in the blank form, which will need further information before determination is rendered.  I would check with your bcbs representative and see if your plan does cover for breast reductions, as this is an exclusion for some.  Even if it is a covered procedure, pre-determination is not a guarantee of payment.  The individual plan's criteria must be met.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.