What is the process on getting approved for breast reduction surgery for Carefirst?

Thank you for the question. Based on your description, you may be an excellent candidate for breast reduction surgery. This operation tends to be one of the most patient pleasing operations to perform.  

“Typical” patients who present for breast reduction surgery are women who have disproportionately large breasts, causing problems such as neck/back/shoulder discomfort, postural changes, bra strap grooving, skin irritation/rashes under the breasts, and/or difficulty with activities of daily living and/or exercise etc. There may be both physical as well as psychosocial “stress” caused by the disproportionately large breasts.

Reducing breast tissue mass and elevating the breasts on the chest wall tend to improve or alleviate many of the symptoms associated with the disproportionately large breasts.Patients considering breast reduction surgery should also consider the potential downsides (risks/complications) associated with the procedure as well. Poor scarring, for example may be associated with the procedure. Additional surgery may be necessary in the short or longer term for a multitude of reasons. Timing of service should be individualized based on the specific patient's life circumstances and preferences.When the time is right, I suggest that you seek consultation with well experienced plastic surgeons who can demonstrate significant experience achieving the types of outcomes you would be pleased with.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. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. 

I hope this, and the attached link (dedicated to breast reduction surgery concerns), helps. Best wishes. 

Every insurance plan has their own unique criteria on whether they will
cover a breast reduction. More and more, we are seeing plans where a
breast reduction is not a covered benefit. If it is a covered benefit,
some insurance plans set a minimum required amount of tissue to be
remove in order to met their threshold for coverage. Some set the amount
in relation to your BMI (height and weight). Others require extensive
medical records documenting neck pain, back pain, and history of rashes.
The other alternative is to opt for a breast reduction as a self-pay
option. Start by visiting with a board certified plastic surgeon to
learn more about your options.Best wishes,Dr. BasuHouston, TX