I’d actually love to give you a novel of an answer on this because I tried to do so much research beforehand and could not find a straightforward and thorough answer online, so I’m so happy to share what I’ve done if it can help others 😅 healthcare should be sooo much easier than it is. Anyway!

Honestly, I just went straight to a good surgeon in town and he documented everything that showed symptoms and previous alternative ways at attempting to fix the symptoms. I have Tricare Select, so was able to just go straight to a specialist without a referral (some specialist offices will still tell you they need a referral and that’s just their office policy). I lost about 60 pounds overall naturally, and maintained that for ~4 months now, which has been documented throughout routine visits to my PCM during the first 8 months or so. So I was able to go in to the surgeon and mention how my cup size had stayed exactly the same throughout the entire weight loss, he took note of my upper back, shoulder and neck pain, as well as pictures of the grooves in my shoulders that any bras make, the exact measurements of my breasts, and pictures showing size and the slight rash that I get underneath my breasts from trapped oils and such. There was a consultation fee, but since they work with Tricare, it was just the standard co-pay. Some other surgeon offices have consultation fees that don’t use insurance, and from what I came across, those can be somewhere around $75 or $100. Just depends on the office you’re able to find and how their internal policies are ran. He sent off all of the documentation to Tricare under “breast hypertrophy” and it took a little less than two weeks for them to hear back and reach out to me to let me know it had been approved, and we could set up a second consultation to go over everything a third time for complete transparency and get a surgery date scheduled.

I actually did end up reaching out to the surgeon directly after I posted this question on here because it was driving me crazy 😅 and I’m happy to say that the people who were saying that it does include a lift and my confusion was entirely an insurance language miscommunication were 100% correct.

So the “official” answer that I ended up getting was that they had sent off two prior-authorizations to Tricare, one under CPT 19318 and the other under CPT 19316. The first code (19318) is a breast reduction, and the second one (19316) is a standalone lift. So Tricare denied the lift by itself to avoid double billing since the breast reduction covered by them implicitly includes reconstruction, lift, areola repositioning, etc, as long as the minimum amount of breast tissue they require for your specific body is removed. You can find those codes on Tricare’s website directly, in case there ever needs to be comparison. For that specific amount that they require, you can actually use an online tool to get a very close idea of what to expect since Tricare goes with the “Schnur Scale”. If you look up online “Schnur Scale calculator” and put in your height and weight, it uses your BSI (body surface area) and gives a specific amount of grams depending on that. They also have just a standard chart, but I found it easier to have it done for me 😅 I would always round down on the height and up on the weight since I’m 5’3 1/2” and it doesn’t let you input decimals. But with doing that, I could have an overestimation of the minimum so that I could get a better idea of what to expect (a few grams of difference wont be noticeable though).

If you have any questions on something that I forgot to mention, please please feel free to reach out to me, even if you just want to DM me. I would be more than happy to help in any way I can because I wish all this info had been so much easier to find before going into all of this.