Will my Federal Employee Blue Cross Blue Shield insurance cover a Breast reduction?

Question

I'm 22 and looking to have a breast reduction. My under bust measurement is 31 inches, and around the bust is 41. This is generally considered around a 32G bra size. I am 5'5" tall and around 170 pounds. I actually fit almost all the criteria I read about but am worried because I'm a bit overweight by BMI standards. My measurements are small - waist is 30 in and my hips 38. But I just tend to be on the heavier side. Is this a barrier to getting the surgery covered? I REALLY want it.

Seth Eberlin, MD · Answer

Thank you for your question.  There are a few things that go into determining whether or not you qualify for a breast reduction.  And in general, plastic surgeons will work hard to try to get your insurance to pay for it.Some of the criteria that are looked at are low back pain, shoulder grooving from bra straps, and skin irritation/infections under your breasts.  If you have these, you would fit the criteria but ultimately it is up to your insurance company as to whether or not they will cover it.My advice would be to make sure you find a board certified plastic surgeon who agrees with and understands your aesthetic goals and who will push against the insurance companies to give you the surgery and the results you deserve.Good luck,Dr. Seth

Jed H. Horowitz, MD, FACS · Answer

Each #insurance company has their own policy regarding #BreastReduction coverage. The best thing to do is schedule a visit with a plastic surgeon who can contact your insurance company for authorization after performing a #breast examination and documentation of your symptoms. You should also consider going to your primary physician for an examination and documentation as well. Insurance companies have a number of requirements and an examination will be able to determine if you are a candidate for reduction. Although some practices do not accept insurance, their staff may be able to assist you in obtaining pre-authorization. Then you can attempt to be reimbursed for out of pocket expenses.

Larry S. Nichter, MD, MS, FACS · Answer

From your description it seems as if you are a good candidate for breast reduction. Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Susan Buenaventura, MD, FACS · Answer

I see many FEP patients for breast reduction out of network and they tend to have very clear criteria about what will be covered in their policy.  There is also the question of whether your individual policy has coverage for breast reduction.  Usually at your current weight, provided you meet their other criteria (your plastic surgeon can go over these at consultation), they would expect 600 Gm or more per breast to be removed for coverage.  Your surgeon will need to estimate the amount that can be removed for you.  BC will not pre approve the procedure, so it is essential to meet with an experienced plastic surgeon to determine if insurance submission is likely to cover you.   It is a life changing procedure!  Best wishes to you.

Keith Denkler, MD · Answer

Insurance companies often will cover breast reduction surgery.It involves an exam, photos, and submitting this to your insurance for pre-approval.Most plastic surgeons are familiar with this process.

Will my Federal Employee Blue Cross Blue Shield insurance cover a Breast reduction?

Answers (5)

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