Are you an Amerihealth of New Jersey member considering a breast reduction and wondering if your insurance will cover it? According to Dr. Rahul Vemula, a board-certified plastic surgeon in West Long Branch, New Jersey, you may be in luck. AmeriHealth NJ is considered one of the more reasonable insurance providers in New Jersey that covers breast reduction surgery. However, specific requirements must be met for Amerihealth to consider providing coverage.
Required Symptoms and Duration
Amerihealth requires patients seeking breast reduction coverage to have certain symptoms present for a duration of six weeks or longer.
These specific symptoms include:
- Back pain.
- Arthritis located in the cervical spine, which refers to the bones in your neck.
- Rashes that develop underneath your breast folds.
- Grooving from your bra straps that measure greater than one centimeter in depth.
- A specific anatomical measurement where your nipple is eight centimeters below the breast fold.
You must meet these symptom criteria for the specified period to be considered a candidate for insurance coverage by Amerihealth.
Requirement for Conservative Therapy
Beyond having the required symptoms, you must also demonstrate that these symptoms have not improved after undergoing non-surgical interventions, referred to by Amerihealth as conservative therapy. The video specifies what Amerihealth defines as conservative therapy. It includes:
- Physical therapy.
- Exercise.
- Using pain medication to manage discomfort.
- Applying topical medication specifically to treat any rashes.
Amerihealth requires proof that none of these conservative therapies have been effective in relieving your symptoms for at least six weeks or so. If these non-surgical methods have not worked, they would then consider providing insurance coverage for your breast reduction.
Minimum Tissue Removal Based on Body Surface Area (BSA)
If you meet the symptom and conservative therapy criteria, there’s another crucial requirement related to the surgical procedure itself. Your plastic surgeon must determine the amount of breast tissue that needs to be removed to achieve symmetry and balance. This amount isn’t arbitrary. It’s linked to your Body Surface Area (BSA).
BSA is a calculation derived from your height and weight. The insurance company, Amerihealth, uses a chart based on your BSA to determine the minimum amount of breast tissue that is required to be removed during the surgery for coverage consideration. If the planned surgical removal meets or exceeds this minimum required amount based on your BSA, then Amerihealth will most likely cover your breast reduction.
What You Can Do Next
Patients suffering from the physical and emotional burden of overly large breasts, and who have Amerihealth NJ insurance, may be eligible for a covered breast reduction provided they meet the medical criteria. Documenting your symptoms, trying conservative treatments, and consulting with an experienced plastic surgeon, such as Dr. Vemula, can all increase your chances of breast reduction insurance coverage approval in New Jersey.
It’s highly recommended to schedule a consultation to evaluate your eligibility and begin the pre-authorization process. With the right approach, you can navigate the insurance process smoothly and move closer to relief and improved quality of life.