So your breasts are very large. You may be experiencing a lot of discomfort related to their disproportionate size – neck, back and shoulder pains that are made worse with physical activities. There may be a constant and uncomfortable heaviness on your chest that is made worse when you lay down. Maybe you are experiencing rashes and skin irritation from your breasts rubbing on your skin.
Perhaps you are embarrassed by their very large size which can lead to some very unwanted attention and even dreaded comments from others.
Maybe you have discussed your breast related issues with your primary care doctor or your ob-gyn doctor and he/she recommended that you consider having a breast reduction.
Whatever the underlying reasons are, your breasts are far too large and you would like to have them reduced in size.
If you do have health insurance, will your insurance company pay for your breast reduction or will you have to pay for the surgery on your own?
Of course, if you don’t have health insurance, there is no mystery as to who will be responsible for the costs of the surgery.
Compared to most other surgical procedures, it can be a far more daunting and time consuming task to determine if your insurance company may “cover” your breast reduction and what you will need to do in order to obtain their approval (authorization) to proceed with the procedure.
To further complicate this, there is at least one insurance company presently, Blue Cross/Blue Shield, which will not give you a definitive approval for coverage prior to surgery. We will discuss this issue later.
Let’s explore each of the steps needed to be taken in order to seek insurance pre-certification (coverage) for your breast reduction. These are listed below. You should also realize that there are many insurance plans with different requirements, even with a given insurance company. Consequently, there may be additional information required.
• Is Breast Reduction a Covered Benefit in Your Insurance Plan?
• Your Symptoms and Their Documentation
• Does Your Anticipated Breast Reduction Volume Meet Insurance Criteria?
• Documentation of at Least Three Months of Therapy to Address Physical Symptoms
• Physician Letter of Documentation
Is Breast Reduction a Covered Benefit in Your Insurance Plan?
Many insurance plans will provide coverage for breast reduction surgery as long as you meet their specific criteria and follow the requirements. However, there are some plans that specifically exclude breast reduction surgery as a covered benefit. You will need to determine whether or not your plan allows for this surgery.
If your insurance plan excludes coverage for breast reduction surgery, there is no appealing this. However, you can still pursue the surgery by paying the costs yourself. We do offer affordable, special self-pay pricing along with financing options.
Your Symptoms and Their Documentation
You must have significant symptoms that are directly related to your enlarged breasts and they have to be documented such as by your primary care doctor or orthopedist. This can include neck, back and shoulder pains, skin rashes and irritation, change in posture, pain when engaging in physical activities, etc. Just claiming that you feel that your breasts are too big, you are very self-conscious about them or that you can’t find clothes that fit due to your breast size are irrelevant for insurance purposes.
Does Your Anticipated Breast Reduction Volume Meet Insurance Criteria?
Virtually all insurance companies require that a specific minimum amount of breast tissue is removed from at least one breast in order to be eligible for coverage. Instead of being a fixed amount to be removed regardless of the person’s body size, it is typically determined by a formula based on one’s weight and height. The criteria do vary among the various insurance companies. If the amount to be removed is not close to the specific requirements then you do not qualify for coverage.
Documentation of at Least Three Months of Therapy to Address Physical Symptoms
Most all insurance companies mandate that you undergo at least 3 months of therapy in attempt to alleviate symptoms related to your enlarged breast size such as neck, back and shoulder pains. Documentation of this treatment along with its failure to resolve your symptoms is absolutely necessary for insurance coverage. Acceptable forms of therapy can include physical therapy, massage therapy and chiropractic care.
Specifics can vary from plan to plan so this will need to be carefully checked.
Physician Letter of Documentation
Often, a letter from your primary care physician is required. This should document at least 3 months of care that was unsuccessful in trying to address symptoms related to the large size of your breasts such as neck, back and shoulder pains, headaches and rashes. Letters from a chiropractor or orthopedic surgeon can also be helpful.
Some Important Things to Remember
Once you have obtained all the above information and submitted it to your plastic surgeon’s office, obtaining pre-certification/authorization can take up to 30 days or even more.
This part can be extremely tedious and time consuming with multiple calls usually required in order to obtain a definitive answer.
Unfortunately, this is not a “one call does it all” speedy and efficient process. So, be patient!
If you have been approved for coverage of your breast reduction, your expected out of pocket expenses and responsibilities can be determined prior to proceeding with surgery. This will include co-insurance, any deductibles that have not been met and other charges.
Finally, it is very important for you to realize that prior authorization/pre-certification is never a guarantee of payment by your insurance company. However, if it is obtained, there is a very high probability that your insurance will pay their part.
As stated above, Blue Cross Blue Shield does not provide pre-authorization. However, if their criteria for breast reduction surgery are met, they will virtually always “post approve” it after surgery.
If you have questions about breast reduction surgery and insurance coverage or want to schedule your consultation for the procedure, you can contact the Arizona Center for Aesthetic Plastic Surgery at (480) 451-3000 or by email.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona