Will Tricare Prime Pay for a Abdominoplasty and a Breast Reduction? (photo)

I have had 2 vertical c-sections. I have lower back pain and getting rashes below the flap of skin. I love to exercise and run but running has caused lots of rashes and pain to my extra skin. I also have rashes developing below my breasts I am 5ft 3 and have 40DDD breasts and would love to have a reduction. I have to wear my bra at all times to feel comfortable and have to wear 2-3 when I go running

Doctor Answers 9

Insurance coverage for tummy tuck and breast reduction--unlikely.

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Depending on your exact height and weight, your insurance company has mathematical guidelines for the minimum amount of tissue that MUST be removed from each breast in order to qualify for insurance reimbursement. The minimum is 400g, or nearly one pound of tissue per breast. Will removal of this amount (or more, depending on the formula) leave you with any breasts? Perhaps, but perhaps not. Impossible to predict without your weight or examination of your breasts, but unless you are OK with disproportionately-small breasts, insurance coverage for breast reduction may not be achievable. You would likely require a "cosmetic" breast reduction or full breast lift to achieve your goals here. This would be self-pay.

Coverage for tummy tuck is doubtful at best. I have been a reviewer for Blue Cross/Blue Shield as well as for Medicare for years, and can tell you that insurance coverage would not be possible in virtually all cases. You do not want to "try" for coverage for even one of these two surgical requests, as hospital charges for these operations are significantly higher than for the same operations performed by the same surgeon at a free-standing outpatient surgical facility or accredited office surgical facility (this is where I operate for elective cosmetic surgeries). Even if one procedure were "covered," your costs for the elective or"cosmetic" other operation would be astronomically higher than self-paying for both in most cases!

Since it is virtually certain that you will be responsible for what is considered "cosmetic" despite your rashes and pain, choose your plastic surgeon carefully and find out what the exact costs are before you decide to proceed. And since you pay out of pocket, YOU and your surgeon get to decide exactly how much breast tissue should be removed, and a true cosmetic tummy tuck can be performed, not just a panniculectomy. Best wishes!

Abdominoplasty, breast reduction, and insurance coverage

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From the picture you sent of your tummy and from your description of your breasts it is clear that you would be a candidate for breast reduction and tummy tuck (abdominoplasty).   It is likely that your insurance company will cover the reduction, but not so likekly that it will cover the tummy tuck.  While each insurance company is different (some even have "carve-outs" specifically excluding breast reduction) it is my experience that 90% will cover reduction as "medically necessary."  To get this coverage I submit photos and a letter for each patient.  In the past 20 years, having performed almost 3000 reductions, my rate of insurance coverage is over 90%.

Abdominoplasty is much harder to get covered. In my experience there has to be an apron of skin hanging below the pubic area along with a documented history of rashes, skin ulcers, etc.

The only way to be sure is to see a board certified surgeon who has a good reputation with insurance carriers and to have photos and a letter submitted on your behalf.  When I believe that there is medical necessity I am happy to appeal any denials all the way up to the medical director.  If you choose a surgeon with this type of experience your chances are better that at least the reduction will be covered.

Insurance coverage for tummy tuck

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Every insurance company has slightly different criteria that must be met before removal of excess skin and fat from the abdomen - panniculectomy, not tummy tuck - is covered.  Generally the skin has to hang down fairly low, and patient must have problems with dampness and rashes.

You do have rash problems and you do have loose, sagging skin.  It is just a question of whether the skin is loose enough and hangs low enough to satisfy your particular insurance company.  I suggest you see a board-certified Plastic Surgeon to discuss this and send a pre-authorization request to "medical review" at your insurance company.

Questions about insurance coverage for plastic surgery

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The question of insurance coverage for your condition requires an examination.  If you have had significant rashes under the overhaning abdominal skin and back pain then a panniculectomy may be covered.  This is not an abdominoplasty but a removal of the excess and over hanging skin.  If you have overly large breasts with symptoms of back, neck and shoulder pain then a breast reduction may be covered.  The next step is an examination by a plastic surgery under your plan

Insurance and breast reduction

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Each insurance company has different criteria for approving surgery. You may very well be a good candidate for a breast reduction and if you have had sginificant weigth loss and have serious intertrigo( rash) issues from an overhanging pannus, they  may approve your procedures. An exam in person is critical.

Does Tricare cover breast reduction and abdominoplasty

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Your insurance company may pay for the breast reduction if you meet its criteria; however, no insurer pays for tummy tucks at this time as this is deemed cosmetic. Documentation and submission of supporting medical evidence is extremely important in obtaining preauthorization for a breast reduction.

Breast reduction/ tummy tuck and Tricare Prime

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In order for the insurance company  to approve your surgery, you have to establish a medical necessary. There is a list of criterial to meet before they can approve your surgery. This list of criteria can be given to if you contact your insurance carrier. Documentation by your PCP, and other specialty that you have symptoms related to large breasts and pannus and doing the above surgery will help your symptoms may increase your chances of having the surgery approved. If they deny it, they should provide you with an explanation.

Moneer Jaibaji, MD
San Diego Plastic Surgeon

Insurance covering Tummy Tuck Surgery and Breast Reduction?

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Thank you for your question.

Each insurance company has their own criteria for covering these procedures.  Breast reduction is usually approved more often than tummy tuck surgery but it does require you to have an examination and send documentation to the insurance company for authorization.

I usually send a letter along with photos and chart notes to the insurance company when asking for authorization.  It would be helpful if you had documentation from other professionals that have treated you for back/neck pain, rashes, etc.

Best wishes. 

Insurance coverage for breast reduction or tummy tuck- possible?

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Each insurance carrier has specific criterias for coverage. However, you would likely be eligible for coverage with the breast reduction if you have at least 500 gram of tissue to be removed from each breast.  If you call your carrier, you should be able to find out exactly what the requirements are.  

Insurance coverage for a tummy tuck is much harder, and not likely.  Out of hundreds of tummy tucks over the past 20 years,  perhaps two of my patients have been eligible for coverage, but they had years of documentation with rashes and infections below the skin flap.   Even if you could get coverage, it would * not * be for a full tummy tuck, but rather just for the panniculectomy, or excess skin. 

Hope this helps!


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.