Will Blue Cross Blue Shield cover my breast reduction surgery?

Question

I am 5'1 and a little under 110lbs. I'm 19years old, and my current breast size is 32DDD. My back is countiously hurting, and Im always hunched over due to pain. Is there a way insurance will cover my surgery?

Randal Haworth, MD, FACS · Answer

With today's insurance plans under the ACA, less and less insurance companies cover breast reduction surgery despite that you may have symptoms such as painful bra strap grooving, neck, shoulder and back pain overly large breasts. However, I suggest contacting your insurance company and asking exactly what is and isn't covered in regards to treating macromastia with a breast reduction.  If they do offer coverage then ask for a list of in network providers whom you can then contact to set up an appointment and consultation with to address your

Kenneth Hughes, MD · Answer

Read your BCBS certificate of coverage.  One path does not work for all patients, and many times it is dependent upon your perseverance.  Breast reductions which are medically necessary i.e. you suffer back, shoulder, and neck pain with documented medical attention are typically covered by medical insurance. If not, your insurance company may try to deny you based upon a lot of things such as weight, lack of symptoms, and lack of previous medical management. Typically insurance companies required 500 grams (3 cup sizes) from each breast. 
Find a board certified plastic surgeon (BCPS) who is in-network with your insurance and schedule a consultation with the BCPS (you may need a referral from your general practitioner).  Look at the BCPS's web site gallery of before and after photos and then schedule a consultation to discuss the best plan for you.  Make sure the BCPS's letter of preauthorization or precertification includes the documentation of your medical necessity. 
Kenneth Hughes, MD, Board Certified Plastic Surgeon
Los Angeles, CA

Shwetambara Parakh, MD · Answer

If your breasts are 32DDD cup and given your height and weight it is very likely insurance should be able to cover your breast reduction.  You should first call and check with your insurance if this is a covered benefit in your plan .
Your next step would be to meet with a board certified plastic surgeon, who will discuss the process with you and if he/she determines that you are a good candidate will then submit the documents and pictures to your insurance company . The insurance will likely also require supporting documents from your medical doctor reg. medical necessity, from physical therapist if you have had any. Once all these documents have been submitted to insurance , they will review it and let you know about the coverage.
Good luck !

Gary M. Horndeski, MD · Answer

Thank you for you question,  The Horndeski Method/The Bellesoma Method is a current technique to lift and/or reduce breasts without using implants or the ugly vertical scars.  The incisions are hidden around the areola and in the inframammary crease. The vertical incision has been completely eliminated. The areola incision heals almost invisibly due to the fact that there is hardly any tension on the closure. With this particular technique, ducts are preserved along with nerve supply maintaining nipple sensation and the ability to breast feed. Because the breast is reshaped internally and is secured to your chest muscles, upper pole fullness is possible without an implant. Attached is a patient who underwent The Horndeski Method/The Bellesoma Method. Please note that her tissue was used to create upper pole fullness and cleavage without any foreign materials (mesh, implants, etc).  Unfortunately, we do not accept insurance for breast reductions.  Dr. Horndeski does not remove enough breast tissue to meet insurance criteria.  Instead, he utilizes the breast tissue to reshape the breast.  It is a proprietary technique that only surgeons that have been trained by me can perform. I hope this helps. Best wishes and kind regards, Dr. Gary Horndeski

Tom J. Pousti, MD · Answer

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. This operation tends to be one of the most patient pleasing operations to perform.
Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, 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. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. 
In regards to the outcome of the breast reduction surgery, the most important decision you make will be careful selection of your plastic surgeon. I would suggest starting with the American Society of Plastic Surgery and/or the Aesthetic Society of Plastic Surgery to obtain a list of well experienced board-certified plastic surgeons.
Then, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery. ***Ask to SEE lots of examples of their work AND preferably speak/see patients who have had similar procedures done.
I hope this, and the attached link, helps. Best wishes.

James McDonough, MD (retired) · Answer

Blue Cross Blue Shield has published guidelines for breast reduction. Consult a board certified plastic surgeon to see if the guidelines match your problem.  They will submit a request for prior approval to the insurance carrier and if approved  will schedule your surgery.

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