Breast Lifts and insurance - ThinnerTimes

Harleykitty · 12-09-2007, 06:14 PM

Does any insurance (and if so which ones) cover breast augumentation surgery. I haven't even lost all of my weight yet and my breasts are already saggy. I can't stand it. I'm sure they are going to be horrible after this is all said and done with. I am not even necessarily talking about implants, althought that would be nice, but do they cover like breast lifts

Zenomia · 12-09-2007, 06:55 PM

Most do NOT! I had them cover the panni part of my belt...but they refused the breast lift. I do know that Beth from MN got hers covered, but it was a severe case!

I have my 1/2 lift/aug on Thurs!

Best Wishes to you!

MiladyB · 12-09-2007, 09:18 PM

I was able to get my breast lift covered but had to call it a breast reduction. I have Priority Health which is a MI based insurance company.

This is the criteria that they have.

Quote:

2. Bilateral reduction mammoplasty is a covered benefit when all of the
following are met:
a. The patient has symptoms adversely affecting activities of daily
living and quality of life due to severe back, neck, and/or shoulder
pain or upper extremity paresthesias, that are directly attributable
to macromastia, and that have not responded to conservative
measures.
b. The operating surgeon documents that the estimated amount (in
grams) of breast tissue to be removed or removed from each breast
must be more than the minimum amount for a given body surface
area (BSA) according to the Schnur Sliding scale (see above)
c. Patient is 18 years or older, and
d. PCP has referred the patient, and
Surgeon notifies Priority Health by fax

3. If the patient does not meet criteria for 2. above, Priority Health
requires all criteria for Set a. OR Set b. below:

Set a.
All of the following:
a. 18 years or older
1. Evaluation by a physiatrist who has determined that both:
i. The pain cannot be solely explained by a
musculoskeletal condition (e.g., arthritis, spondylitis,
acromioclavicular strain)
and
ii. Reduction mammoplasty is likely to result in
improvement of the chronic pain
2. The patient has a symptom score greater than or equal to 3
based on the following:
Severe Moderate/Mild
• Digital (finger) paresthesias 3.0 1.5
• Occipital headaches 2.0 1.0
• Cervical lordosis, thoracic kyphosis, or neck pain 2.0 1.0
• Lumbar lordosis or low back pain 2.0 1.0
• Breast pain 1.0 0.5
• Grooves on shoulder from brassiere or shoulder pain 1.0 0.5
• Intertrigo: rash under breasts 1.0 0.5
• Asymmetry of the breast (>30% difference) 1.0 0.5

Set b.
All of the following:
1. 18 years or older
2. Persistent pain and related symptoms despite at least a 6
month trial of therapeutic measures including all of the
following:
i. Supportive devices (e.g., proper bra support/fitting,
wide bra straps)
ii. Analgesic/NSAIDs
iii. One of the following: Chiropractic care/physical
therapy/exercises/posturing maneuvers/osteopathic
manipulation
3. The patient has a symptom score greater than or equal to 3
based on the following:
Severe Moderate/Mild
• Digital (finger) paresthesias 3.0 1.5
• Occipital headaches 2.0 1.0
• Cervical lordosis, thoracic kyphosis, or neck pain 2.0 1.0
• Lumbar lordosis or low back pain 2.0 1.0
• Breast pain 1.0 0.5
• Grooves on shoulder from brassiere or shoulder pain 1.0 0.5
• Intertrigo: rash under breasts 1.0 0.5
• Asymmetry of the breast (>30% difference) 1.0 0.5

My surgery was covered under "Set a". I no longer had the breast weight to get it covered under the first criteria but was able to get it covered on medical conditions alone. I had to have documentation from my PCP and a Physiatrist in regards to the medical problems. I had low back pain, neck pain, rashes and occipital headaches. All were in mild form but with 6 months documentation with my PCP and a consult with a Physiatrist I was able to get it covered.

Phoenixfire · 12-11-2007, 09:18 PM

One of the key criteria is the actual weight of the breast. If they get deflated fter WLS then the weight is often too low to qualify for reduction being covered by insurance. Documented back and neck pain helps. My doctor did these measurements: circumferences, distance from collarbone, etc. I have YEARS of back and neck pain treatment. I may get approved. But the WEIGHT of the breast matters. Because they're just sucking out fat when they do reduction. If they're not heavy with fat anymore (after WLS) then it makes it harder to get it approved.

twodogsmom · 12-21-2007, 01:10 PM

I have BC/PPO ins and they just paid for my mastopexy and abdominoplasty. I never even had to fight with them. Their criteria are (1) skin issues, (2) being unable to get clothing that fits. They will not, howver do anything until you are 18 mo out from your GBP and weight stable. I had several docs from different specialities that I see for various health isues all submit letters, and I submitted a letter sort of summarizing all the reasons I needed both procedures and 2 weeks late-BINGO! Surgery was 12/10, breasts not painful now but the abd. muscles are screaming! Good luck., PM if I can advise. Linda

Gina in NY · 12-22-2007, 07:37 PM

My plastic surgeon says that basically, in NY, no one covers a breast lift. Like Beth said, it has to be a reduction with about a pound coming off each side. Like I had a pound left?? Anyway - This is a man who gets 85% of panni's covered, so I'm sure he's tried. But I would bet it is different in different places.

twodogsmom · 12-23-2007, 04:49 AM

All the docs I consulted with were amazed that I got the mastopexy covered by ins, so never give up without trying. Sometimes you have to just know how to make the ins. system work and which of their buttons to push.