What are the prerequisites I need to do to have Horizon BC/BS NJ Direct cover a breast reduction?

Question

I need advice on how to go about getting a breast reduction covered. I'm 5'3", 146 Ibs, and I have 36 I/J's. I would love to go down to a C, as my breasts cause me immense back pain that a chiropractor can't relieve. My left is also larger than my right. It's really frustrating that I can no longer run or work out comfortably, and everything I wear is either inappropriate if it is fitted, or I have to buy two sizes up. If someone has advice on how I should go about this, it would be appreciated.

Urmen Desai, MD, MPH, FACS · Answer

You need to have certain medical symptoms.   I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, 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), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

Reza Momeni, MD, FACS · Answer

Blue cross does a nice job of listing their requirements on their website. You can also always ask them to mail you their criteria.In my experience when you meet their criteria, they are very good about covering the treatment.  When you don't, they don't cover it.  It's rather simple. Breast reduction eligibility and coverage by insurance varies from one insurance carrier to the next, and cannot be determined based on cup size, but only based on an in-person examination to figure out how much tissue the surgeon needs to remove.  You also often have to qualify for multiple other criteria from your insurance carrier, so be sure to request their breast reduction coverage policy ahead of time before your plastic surgery visit to ensure you meet all the other non-size related demands that they have.  Be sure to discuss your goals and concerns with your board certified plastic surgeon and consider the pros and the cons. Be certain your surgeon is properly certified.  I've attached a link where you can start your search.

Robert L. Kraft, MD, FACS · Answer

The criteria are accessible online under either breast reduction or reduction mammoplasty. Despite your size and fulfillment of their basic criteria, Horizon is notorious for requiring conservative management including chiropractic or physical therapy for a set time frame, spine X-rays and an orthopedic consult. Yes, a waste of your time and copays but it is a way to hold back on approvals.  BCBSs nationally each use different criteria and, or some reason, are much more stringent in the NY/NJ area than elsewhere in the country. If you persevere, you should be able to obtain coverage for the procedure. Best wishes.

Daniel Schmid, MD · Answer

BC/BC NJ requires 6 months of pt and two doctors notes other than the plastic surgeon recommending reduction prior to authorization.  They will not approve without these three things.  If you have not tried PT you should do so for 6 months prior to attempting authorization.  Good Luck!

Steven Wallach, MD · Answer

You would need to first find out from Horizon about their criteria for approval.  Then go to a plastic surgeon for evaluation. Good luck.

What are the prerequisites I need to do to have Horizon BC/BS NJ Direct cover a breast reduction?

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