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

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!

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. 

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!