Insurance Coverage for Breast Reduction? (photo)

I am 26, 5'3", 130lbs. I have always had large breasts, suffer from the usual symptoms of them. I was measured last week and am a 32G (although some Fs fit). I was referred to a PS by a my PCP. PS said I am probably boarder line for my insurance (carefirst bluechoice) covering it. One breast is slightly larger and he said that one probably meets the criteria, but the other one may not. Can anyone tell me if there is any sort of appeal process if I get denied and if you think I'm a candidate?

Doctor Answers 6

Insurance may or may not pay for breast reduction.

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On balance it looks as though you would receive a functional improvement by breast reduction which historically was covered by insurance. Times have changed however and certain criteria must be met before insurance will cover breast reduction if at all.

Breast Reduction and Insurance

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I can't comment on whether a specific insurance company will cover breast reduction for a specific patient--there are too many variables.  What I can tell you is that you have the best chance of success if you can document that you incur expenditures related to your breasts, including visits to a doctor for the neck pain, shoulder pain and rashes you've mentioned.  Prescriptions for physical therapy, braces or medicated creams might help too.  Unfortunate though it is, in order to be considered for total or partial reimbursement you need to show that breast reduction is a good investment for your insurance company in the long run as well as for you.

As the other surgeons have suggested, the only way to be sure is to call your carrier and ask about their rules.  Many companies do have an appeal process--you're smart to be thinking about it already.  Some patients do win approval the second time around.

I hope this works for you.  Breast reduction can really give you a new lease on life, and you do appear to be a good candidate.  There are financing options available if you're open to that idea.

Elliot Jacobs, M.D.

New York Plastic Surgeon

Insurance Coverage for Breast Reduction? (photo)

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You appear as an excellent candidate for breast reduction. But health insurances recently have place "major" restrictions on approving reductions. It os based upon the terms of your plan. Best to see the PS than have a predetermination letter sent to your health insurance. 

Insurance and breast reductions

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Coverage for this procedure varies from company to company and policy to policy.  You can phone your insurance carrier to inquire about the criteria required by them for this procedure to be a covered benefit.  If you have this information when you visit your doctor it may help to shorten the approval process as the surgeon can submit all required information at once.  I would recommend a visit a board certified plastic surgeon who has experience with breast reductions. Good luck.

Mennen T. Gallas, MD
Katy Plastic Surgeon

Insurance will often cover breast reductions

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Thank you for your question and for providing the photos. Based on the information you provided, it seems you are a candidate for a breast reduction.  Whether or not your insurance will cover it is another matter.  The criteria for insurance to cover the procedure can vary by state.  In our office in New York State, we have an insurance coordinator who acts on the patients behalf, working with the patient's insurance company to determine if insurance will cover the reduction.  Find out if your plastic surgeon's office will contact your insurance company on your behalf.  They may not.  If not, you can call your insurance company and find out if your policy includes coverage for a breast reduction; it must be a covered benefit stated in your policy.  If your policy does provide coverage for breast reduction, then the question is whether or not you meet your insurance companies criteria.  In other words, does the insurance company think it is medically necessary for you to have a breast reduction. This usually depends on how much weight is going to be removed from each breast and what your symptoms are.  Find out from the insurance representative what steps you need to take to get "pre-certified"; again this varies state by state.  This is the hard part because you need to know what is the minimum amount of weight the insurance company requires to be removed, do you need an opinion from a neurologist, etc. that supports the need for a breast reduction.  If your insurance company says that you do not meet the criteria, you can appeal the decision.  With persistence you can work through the system to get an answer, but it is easier if someone who works with the insurance companies on a regular basis helps you with this.  If your plastic surgeon's office does not offer this service, you could call around and see if anyone in your area does.  Keep in mind that even if the insurance company pre-certifies you for a breast reduction, there is no absolute guarantee that they will pay for it. In New York State, once a patient is pre-certified the insurance company will almost always pay for it, but occasionally they do not.  Again, this can vary state to state.   Hope this helps.  Tracy M. Pfeifer, MD, MS 

Insurance Coverage for Breast Reduction?

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Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.
Based on your description you may be a good candidate for breast reduction surgery. Unfortunately, online consultants will not be able to provide you with meaningful advice when it comes to probability that health insurance companies will provide coverage.
The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.  

 When dealing with health insurance companies, prepare to be persistent.  There is usually an appeal process in the event that the initial authorization is denied.

 Best wishes.
Best wishes.

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.