Does horizon nj health cover breast reduction surgery

Policy: Gender Reassignment/Gender Affirming Surgery
Policy Number: 115
Last Update: 2021-06-07
Issued in: New Jersey

Body Contouring:

1. Non-genital, non-breast aesthetic surgical procedures are considered cosmetic in nature, even in the presence of a contract benefit for gender affirming surgery. These include, but may not be limited to, the following:
   
   1. Procedures that assist in feminization (male-to-female):
      
      1. reduction thyroid chondroplasty (trachea shave)
      2. suction-assisted lipoplasty of the waist
      3. rhinoplasty
      4. facial feminization surgery / facial bone reduction / jaw shortening / sculpturing
      5. face-lift
      6. blepharoplasty
      7. voice modification surgery (vocal cord shortening)
      8. hair reconstruction / hair removal / electrolysis
      9. rhytidectomy
      10. gluteal augmentation (implants/lipofilling)
   2. Procedures that assist in masculinization (female-to-male):
      
      1. voice modification surgery to obtain a deeper voice (rarely done per WPATH Standards of Care )
      2. liposuction (e.g., reduce fat in hips, thighs, and buttocks)
      3. pectoral implants
      4. chin implants
      5. lip reduction

Breast Reconstruction:

1. Criteria for mastectomy and creation of a male chest in female-to-male members:
   
   1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
   2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
   3. Capacity to make a fully informed decision and to give consent for treatment; and
   4. Age of majority (18 years of age or older) - For members younger than 18 years of age, please see NOTE below; and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
      (NOTE: Hormone therapy is not a prerequisite.
      According to the WPATH Standards of Care 7th Edition, ”Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”)
2. Criteria for breast augmentation (implants/lipofilling) in male-to-female members:
   
   1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
   2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
   3. Capacity to make a fully informed decision and to give consent for treatment; and
   4. Age of majority (18 years of age or older); and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
      (NOTE: Although not an explicit criterion, WPATH Standards of Care (Revision 7 p. 65) recommended that male-to-female members undergo feminizing hormone therapy (minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical/aesthetic results.)

Youth Services:

For mastectomy:

For members younger than 18 years of age, please see NOTE below;

(NOTE: Hormone therapy is not a pre-requisite.

According to the WPATH Standards of Care 7th Edition, "Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.")

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Updated on Nov 29, 2021

Women who have overly large breasts that cause them pain are often great candidates for breast reduction. However, one of the most common reasons that patients do not move forward with the surgery is concern about the cost. On top of that, the process of getting their insurance company to cover the procedure can be long and burdensome for some of our patients here in New Jersey. Breast reduction insurance is still very possible. In fact, some of the best news that our patients hear is how passionate and experienced Dr. Comizio is with working with health insurance companies. As a woman herself, Dr. Comizio brings a very active and involved style of patient care and has a long track record of getting her patients coverage for their breast reduction.

Cosmetic versus Medical Breast Reduction

Most insurance companies will not cover a breast reduction simply for cosmetic reasons. However, if the patient and the surgeon can prove that the procedure will offer the patient medical benefits, then they will often cover the procedure. The process for getting coverage may be tiresome and take a lot of paperwork, but in the end, it is worth it for her patients in New Jersey.

Breast Reduction Insurance Consideration

Now, the process for proving that the procedure will bring medical benefits must address several factors.

• How large is the reduction? If the reduction is large enough, the patient may have a good chance of getting insurance coverage. New Jersey patients that have an G-cup or larger and are going down to a C-cup can make a great case to their insurance provider. But Dr. Comizio will always counsel our patients not to go too small just to satisfy the insurance company.
• How much tissue and fat is being removed? Insurance companies will usually require the surgeon to describe the exact weight of the tissue to be removed. Anything above 500 grams (1.1 pounds) from each breast is often covered.
• What is your weight and height? Insurance companies may require the surgeon to submit your height and weight. This is because they want to make sure that the patient’s large breasts aren’t caused by obesity.

Submitting the Request for Pre-Certification

For women in New Jersey, breast reduction insurance approval will usually require their surgeon to submit all of the required information for pre-certification. The insurance company will look through it and make a determination if they are going to cover it. This is the part of the process where our patients get the benefit of all of Dr. Comizio’s experience working with insurance providers. She knows all of the different pieces of evidence that they’ll look for and makes sure to include them in her request. We always ask for pre-certification in writing so that our patients have absolute confidence in moving forward.

Dr. Comizio: Your Breast Reduction Advocate in New Jersey

Breast reduction insurance can be a tricky and exhausting process. But our patients absolutely love how bold and assertive Dr. Comizio is on their behalf. Breast reduction is one of the procedures that Dr. Comizio has studied and researched most during her Ivy League education. She has written numerous scholarly articles on breast reduction and continues to give lectures and speeches about it at conferences. Because patients experience some incredible benefits and relief from breast reduction, Dr. Comizio always does her best to get her patients coverage.

Dr. Comizio is in-network with many of the major health insurance providers and has a great deal of experience working with all of them. Plus, as an in-network doctor, many of our New Jersey patients meet their deductible/coinsurance requirement and have no further out of pocket expenses after that.

How to Get Started with Dr. Comizio

If you’re tired of your large, pendulous breasts causing you back, neck, and shoulder pain, and not being able to sleep comfortably or fit into the clothes you want, call Dr. Comizio today at (973) 775-9248. Imagine finally having light and perky breasts that don’t interfere with your activities. We would love to talk with you and learn more about your concerns. In fact, one of our favorite things is getting calls from our patients here in New Jersey. Breast reduction insurance can seem intimidating at first, but we are experts in helping you navigate it.

When you call, you’ll get to speak with one of our friendly and highly trained staff. The next step is to schedule your first consultation with Dr. Comizio. During this first meeting, you’ll get to talk with Dr. Comizio about any discomfort and other issues that your breasts are causing you. Dr. Comizio will also ask you about your medical history, and perform an examination. She will also review your mammogram history, when applicable based on age.

From there, Dr. Comizio will begin developing a treatment plan that she will discuss with you in great detail. This treatment plan includes what size breasts you would like at the end, the shape you would like, and how much tissue she may remove from each breast. After that, the next step in the process is to submit a request for pre-certification to your insurance and wait to see if it gets approved. As we mentioned above, if your request is denied you are entitled to an appeal, and we can help with that as well.

For more information on breast reduction insurance, call our New Jersey office at (973) 775-9248 to get started.

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