Breast reduction surgery, or reduction mammaplasty, is a type of plastic surgery that involves the removal of excessive amounts of breast tissue, skin, and fat, resulting in the reduction of breast size. Some insurance companies wont cover breast reduction unless the surgeon plans to remove at least 500 grams (more than one pound) of (1) Mar 8, 2019 Generally speaking, breast reconstruction surgery is only covered by insurance if the procedure is deemed medically It is certainly possible to get insurance coverage for breast symmetrizing procedures. Copy. A: Your insurance carrier's (Anthem) policy will determine if they cover Breast Reduction surgery. (1991) at the request Procedure Codes. Benefits for reduction mammoplasty following contralateral mastectomy will be allowed as part of a reconstructive sequence to achieve symmetry. the following procedures, when requested alone or in combination with other procedures, are considered cosmetic and not medically necessary when applicable reconstructive criteria above have not been met, or when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender affirming surgery, Gynecomastia, Reduction Mammaplasty for Breast Related Symptoms, Risk-Reducing Mastectomy, and Surgical Management of Breast Implants when it is medically necessary because the criteria shown below have been met. Hi, based upon your symptoms you have listed as well as your size, it sounds appropriate to be evaluated for a breast reduction. Yes, insurance cov If your implants were put in after a mastectomy and your doctor believes that removing your implants is medically necessary, then your health insurance is legally obligated to cover your breast implant removal under the Womens Health Reconstructive breast surgery is a surgical procedure that is designed to restore the normal appearance of a breast after a medically necessary mastectomy for breast cancer or other medical condition, injury or congenital abnormality. Mastopexy: Mastopexy is covered when associated with a reconstructive procedure. To request your personal consultation, call (714) 538-8549 or complete our online contact form today. Precertification is not necessary nor is a minimum number of grams required. for gender affirming breast augmentation procedures only: for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician, and insufficient breast development has Upper eyelid surgeries 11921. Kerrigan CL, Collins ED, Kim HM, Schnur PL, Wilkins E, Cunningham B, Lowery J. They are the only studies among eight performed in different countries that did not show a mortality reduction benefit of mammography of the widespread influence it has had on breast screening guidelines for younger women. She says she often sees The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. He and his staff may be able to help you work with your insurance provider to help qualify you for coverage of your breast reduction procedure. Back, neck or shoulder pain from macromastia and unrelieved by 6 months of: Conservative analgesia, Supportive measures (garment, etc. Anthem is reducing their coverage for Electric Breast Pumps so much that patients may not be able to receive a quality breast pump effective 4/01/18. for the treatment of Hoosier Healthwise (HHW) Hoosier Healthwise (HHW) is Indianas Medicaid plan for pregnant women and children. 1. Some health plans accept those age 16 or older, as long as they have reached breast maturity, as evidenced by a stable cup size for over 6 months. Breast reduction for symptomatic macromastia. Reduction mammaplasty may be considered . HHW provides health care, including doctor visits, prescription drugs, mental health care, dental care, hospitalizations, surgeries and family planning at little or no cost to the member or the member's family.

*Repeat reduction mammoplasty/breast reduction requests will be reviewed by the Medical Director for individual consideration. Coverage Indications, Limitations, and/or Medical Necessity. A breast cancer survivor accused Anthem Blue Cross of denying her coverage for a 3-D mammogram, instead telling her it wasn't medically necessary and Breast reconstruction may also be medically necessary, not cosmetic, when performed to correct congenital defects such as the complete absence of breast tissue (Polands syndrome), developmental abnormalities, trauma, infection or following other therapeutic surgeries, such as breast reduction procedures. Here are sample letters of medical necessity written for women with either ruptured silicone gel implants, severe capsular contracture, or breast pain. Medical Decision Making. Reduction mammoplasty. Click to read their guidelines. Yes, you sound like a good candidate for a Breast Reduction. Breast Reduction Surgery Preliminary Requirements 6 month documentations of all conservative measures that have been taken to relieve pain/discomfort Rashes: treatment with either prescription and over the counter medication/creams. Benefits Application This medical policy relates only to the services or supplies described herein. Other factors can also rule out breast reduction surgery. Breast reduction surgery is generally not covered by insurance. However, it is possible to have the procedure covered if it is medically necessary. Unless the patient can show that they have an underlying condition, breast reduction surgery is generally considered a cosmetic procedure. Medicaid can pay for your breast reduction procedure in various instances. According to a 2020 study in Plastic and Reconstructive Surgery, the average outpatient cost of breast reduction is $9,077, while the average inpatient cost is $19,975. Our technique provides an exceptional breast lift, upper pole fullness, relief from neck and back pain, and no vertical breast lift scar. First of all, the original reason for getting your breast implants matters to health insurance companies (as well as Medicare and Medicaid). Some protocols on the medical necessity of reduction mammaplasty are based on the weight of removed breast tissue. 19. Your insurance carrier's (Anthem) policy will determine if they cover Breast Reduction surgery. Give them a call or check in with the Human Resource Dept. where you work. Yes, you sound like a good candidate for a Breast Reduction. Best Answer. Anthem mothers may no longer have access to a quality double-electric breast pump necessary to support breast milk feeding. Following a radical mastectomy, a woman requires breast reconstruction to replace tissue and nipple. Back pain/neck pain: seen by chiropractor or physical therapy use of prescription or over the Rising Rates of Insurance Denial for Breast Reduction Surgery. where you work. However, for your procedure to be approved by Medicaid, it must be deemed medically necessary by an authorized health practitioner. Medical Policy An i ndependent m ember of the Blue Shield Association 7.01.21 Reduction Mammaplasty Original Policy Date: December 4, 2015 Effective Date: April 1, 2022 Section: 7.0 Surgery Page: Page 1 of 12 . Medical necessity criteria for breast reduction surgery The patient must be age 18 or older. In such scenarios, its common for the insurance company to pay for the reduction, but not the lift. Please email for assistance. 1-9 an important issue is whether breast reduction is a functional need or cosmetic.

I have seen cases like yours get covered. The basis of weight criteria is not related to the outcomes of surgery, but to surgeons retrospectively classifying cases as cosmetic or medically necessary. The criteria for insurance coverage of breast reductions varies depending on the insurance company, and on the specific insurance plans within that The surgeon will aid in submitting your case to your insurance. Give them a call or check in with the Human Resource Dept. Dear Gwendolyn,Hello and thank you for your excellent question. If you are interested in having your insurance cover your breast reduction, you sho Anthem Blue cross will pay for a breast reduction ONLY if it is medically nessacary and is not pre-exisiting. To get this you must: be enrolled in Medicare have had breast surgery as a result of breast cancer not have purchased and claimed under this program in the past 2 years. Policy Statement . A medically reasonable and necessary breast reduction could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms: a. Electric breast pumps are an important resource for maintaining a milk supply to feed your baby. According to Revere Health, Cosmetic surgery is an optional, or medically unnecessary, procedure designed to improve someones appearance. One example of cosmetic surgery is a breast augmentation that does not involve breast reconstruction. However, breast reduction surgery is deemed to be cosmetic and not medically necessary for: poor posture breast asymmetry pendulousness problems with clothes fitting properly nipple-areola distortion psychological considerations Please refer to the Medicare only pays for breast reduction for the first two reasons. May-June 2002, p. 208-217. ), 11922. I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with. Finally, make sure your surgeon This means that your breast reduction has to be related to a medical condition. According to its updated policy, Anthem Blue Cross/Blue Shield recognizes electron based IORT as medically necessary for suitable breast cancer patients as defined by ASTRO APBI guidelines. Breast reconstruction or a breast lift may be necessary for optimal results in addition to the reduction. The patient must have had at least two of the following symptomsfor at least one year. 20. It uses a womans OWN breast tissue to produce an internal suspension technique, without the need for a breast implant. Miller AP, Zacher JB, Berggren RB, et al. (It weighs between 400 grams to 2,000 grams, or about 1 to 4 pounds.) Abstract: Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained. Good luck on your journey. Reduction Mammaplasty: Defining Medical Necessity. The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 13, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin. The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 13, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin. 11920. Thank you for asking about your breast reduction.I am so sorry you have lived so long with such a problem.You are an excellent candidate for a brea Enroll Renew Am I eligible? Jul 29, 2020 Phillips. For some patients, the documentation differentiating between a cosmetic and a medically necessary Schnur et al. Reduction mammaplasty is considered medically necessary when all criteria are met. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. : A capsulectomy is not medically necessary for saline implant removal. The policy defines the treatment as an alternative to whole breast irradiation in the treatment of early stage breast cancer. 1 Nonsurgical Breast Reduction. Nonsurgical breast reduction is an option for women who desire smaller, lighter breasts, but do not want to undergo reduction mammoplasty surgery. Nonsurgical breast enhancement methods are far less reliable and some might even be a complete waste of time and money. It is vital that consumers exercise special care A check of several major insurance providers yields a general list of symptoms and conditions that may constitute a medical necessity for breast reduction: Female breast hypertrophy (increase in tissue volume) Persistent pain in the back, neck and/or shoulders with accompanying muscle spasms Chronic skin irritation in the fold below the breast Of course, when a patient has breast cancer, breast reduction or mastectomy surgeries are often medically necessary. Services that do not meet the criteria of this policy will be considered not medically necessary. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). Breast reduction surgery may help relieve some health issues, such as chronic back and neck pain, rashes and skin chafing underneath the breasts. It is good to get a In both of these situations, the breast reduction is considered medically necessary, so Medicare will cover it. The surgery is covered 90 percent of the time when the tissue to be removed meets insurers standard criteria. The first step would be finding your plastic surgeon who is contracted with your insurance and go from there. Mastopexy. You can get up to a maximum of $400 for each prosthesis. Revision History : Oct. 8, 2021 Added to Limitations Exclusions: - Breast implant illness or silicone implant illness are not medically necessary indications for breast Help with the cost of an external breast prosthesis after breast cancer surgery. Can objective predictors for operative success be identified? medically necessary .

If you would like more information about breastfeeding or prenatal education, please call Provider Services and ask for the Prenatal Project Coordinator: 1-888-285-7801 in Los Angeles County. For some patients, the presence of medical indications is clear-cut: a clear documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. The goal of Medical Necessity: I. Nipple tattooing: The Company considers nipple tattooing (CPT Codes 11920, 11921, 11922 and applicable ICD-10-CM Procedure Codes) medically necessary and eligible for reimbursement providing that at least one of the following medical criteria is met: Malignant neoplasm of breast or nipple; or