Does Medicare Pay for Breast Reduction Surgery?
Yes. Medicare will pay for breast reduction surgery in cases of well documented ‘medical necessity’. Oversized breasts (macromastia) or breast hypertrophy the most common conditions necessitating breast reduction surgery. These conditions cause of debilitating neck, back, and shoulder pain. Medically necessary symptoms also include difficulties with hygiene, skin infections, deformity of the spine, breathing problems, and a myriad of psychological conditions.
Medical necessity is also predicated on a person’s ability to perform normal daily activities. A simple measure is: Do your breast make if difficult to drive, grocery shop, maintain a job, or sleep?
If your breast reduction surgery qualifies for Medicare coverage and is approved by the insurance carrier, there will be a Medicare Part A deductible of $1,600 (2023) for each inpatient hospital benefit period before Original Medicare starts to pay. There’s no limit to the number of benefit periods in a year, and you be subject to the deductible more than once in the same year. Relating to the hospital stay, your can expect Medicare Part A to cover the first 60 days, with a daily copayment everyday after 61 days.
Medicare will not pay for breast reduction medical procedures for elective or cosmetic purposes.
Medicare Coverage of Medically Necessary Breast Reduction Surgery
Medicare (CMS) refers to breast reduction surgery as “reduction mammaplasty” (also spelled ‘mammoplasty’). Reduction Mammaplasty surgically removes glandular tissue, breast fat, and breast skin from the breast.
The objective of reduction mammaplasty is to create a breast size that is clinically normal. Clinically normal breasts are proportional to the body’s size with a symmetrical and balanced appearance.
Breast reduction surgery is a relatively invasive medical procedure for women that can be performed as an impatient procedure (paid by Medicare Part A), or as an outpatient procedure (paid by Medicare Part B).
How Do I Get Preauthorized for Breast Reduction Surgery?
In order for Original Medicare or Medicare Advantage Carriers to pay for breast reduction surgery, patients will need a preauthorization or predetermination approval that attests to the medical necessity of the procedure.
There are many situations where Medicare insurance companies deny predetermination. The most common reasons for carrier denial include obesity, insufficient amount of breast tissue able for removal, and insufficiently documented symptoms. In fact, some insurance companies require over a year’s worth of medical documentation that demonstrates diligent attempts of non-surgical treatments such as supportive bras, anti-inflammatory medications, massage therapy, and chiropractic treatment.
Insurance Carrier Approve Rate for Breast Reduction Surgery: 72%
A National Health Institute study over a five-year period (2012 to 2017) analyzing nearly 300 reduction mammaplasty preauthorization submissions for carrier approval request, found that 1 in 4 (28%) were denied.
The denial rate was 18% at the beginning of the study in 2012, and increased to 41% just 5 years later (2017). Carriers generally denied approvals for 3 reasons: (39%) insufficient medical documentation and not meeting ‘medical necessity criteria’; (30%) insurance policy exclusion; and (12%) insufficient justification that the volume of breast reduction would support the expected outcome.
If you were denied a breast reduction surgery preauthorization by your Medicare insurance company, should you submit an appeal?
Yes. 72% of the people who were denied preauthorization by their insurance carrier were successful in reversing the result – when they appealed the carrier denial (13 successfully reserved of 18 appeal claims in the NHI study). If you were denied a preauthorization for breast reduction surgery, do not just accept the decision. If you were denied preauthorization, don’t hesitate to question the reason for denial and submit a formal appeal for preauthorization.
Medicare Pays for Breast Reduction Surgery for Macromastia Conditions That Limit Everyday Activities
Medicare’s has a process for determining medically necessary breast reduction surgeries. Fundamentally, the underlying health symptoms of having overdeveloped breasts must demonstrate a history of disruption to the candidate’s “Activities of Daily Living”.
Medicare Recommends a 6-Month Review Period Symptoms Associated with Shoulder Pain or Arthritic Spinal Change
Supporting Medicare’s process for medically approved pre-authorization, breast reduction surgery candidates must participate in a 6-month review to satisfy insurance underwriting conditions of “medically necessary”. If the requisite conditions are not observed a doctor, the breast reduction surgery may be deemed as cosmetic.
For a period of 6 months, a Medicare eligible candidate for reduction mammaplasty must show ongoing disruptive symptoms associated with either back and shoulder pain, or arthritis within the upper thoracic or cervical spine. Some insurance carriers like Aetna require a one-year period of pre-authorization review.
Will My Medicare Insurance Carrier Pay For Breast Reduction Surgery?
Medicare insurance companies maintain slightly different criteria and medical information for reduction mammoplasty approval. Surprisingly, health insurance carriers have different coverage guidelines and coverage exclusions. Breast reduction procedures require a pre-authorization by your Medicare insurance provider. Unfortunately, you may encounter difficulties with a breast reduction pre-authorization. Health insurance and Medicare carriers are becoming increasingly restrictive and denying more predetermination requests for reduction mammaplasty.
Many plastic surgeons who specialize in breast reduction believe the criteria used for pretermination is inconsistent across all the different carriers. Interestingly, these predetermination criteria differ from CMS provided recommendations. Plastic surgeons recommend that as you consult with your primary doctor and a Medicare approved plastic surgeon early in the process. Additionally, plastic surgeons recommend that you review your insurance company’s policy coverage detail immediately.
Size Matters with Breast Reduction Carrier Pre-Authorization
88% of Medicare carriers require a minimum breast reduction volume (by breast) by either ‘minimum wight per breast’ or ‘volume based on BSA’. Some insurance companies generally authorize and pay for breast reduction procedures where at least (at a minimum) 400 to 500 grams (0.88 to 1.1 pounds) are removed in each breast.
According to a study by the National Institute of Health, 63 insurance carriers were analyzed regarding breast reduction surgery preapproval requirements. Almost universally, insurance carriers required documented symptoms associated with shoulder and back pain. 88% of Medicare insurance carriers require a minimum breast reduction volume (by breast) by either ‘minimum wight per breast’ or ‘volume based on BSA’. Some insurance companies generally pay for procedures where at least 400 to 500 grams (0.88 to 1.1 pounds) removed in each breast.
Does UnitedHealthcare pay for breast reduction surgery?
No. Most UnitedHealthcare insurance plans detail exclusions for breast reduction surgery, unless the procedure is in connection with a mastectomy and covered under the Women’s Health and Cancer Rights Act of 1998.
Some UHC insurance plans may allow breast reduction surgery if UHC determines the surgery will successfully treat a physiologic functional impairment. UHC is considered to by Board Approved Plastic Surgeons to be a difficult insurance carrier to work with when it comes to breast reduction surgery pre-authorization.
To view UHC’s breast reduction surgery policy and list of preauthorization documents, visit:UnitedHealthcare’s Medical Policy for Breast Reduction Surgery (PDF)
Does Blue Cross Blue Shield pay for breast reduction surgery?
Yes. Blue Cross Blue Shield will cover breast reduction surgery when (in the word of BCBS), the patient selection guidelines in the policy are met, or performed in conjunction with medically necessary breast reconstruction for the purposes of attaining breast symmetry (subject to the terms of the patient’s respective insurance policy). A survey of Board Certified Plastic Surgeons demonstrates a favorable review of BCBS’s breast reduction surgery pre-authorization process and approval rate.
BCBS requires that the amount of breast tissue that needs to be removed by breast reduction surgery from each breast must be greater than or equal to the 22nd percentile on the Schnur Scale. Additionally BCBS requires history of medically documented pain in the neck or shoulders or postural backache which must be of long-standing duration. BCBS expects breast reduction surgery patients to have exhausted conservative therapy options like support bras, exercise and weight management, anti-inflammatory heat/cold treatments, anti-inflammatory medications and muscle relaxants.
To view BCBS’ breast reduction surgery policy and list of preauthorization document requirements, visit: Blue Cross Blue Sheild Medical Policy – Breast-Related Symptoms (PDF)
Does Cigna pay for breast reduction surgery?
Yes. Cigna will cover breast reduction surgery. Under Cigna’s umbrella of plans, breast reduction surgery is medically necessary for the treatment of macromastia when at least one of the debilitating conditions and symptoms persist despite best efforts with alternative medical treatments and therapies: shoulder, upper-back, and neck pain, or ulnar nerve palsy for which no other medical cause has been found on appropriate evaluation, intertrigo (skin inflammation), dermatitis, eczema, or hidradenitis at the inframammary fold (painful lumps to form under the skin where the breast meets the chest).
Cigna requires that the average grams of breast tissue to be removed in each breast is above the 22nd percentile on the Schnur Sliding
Scale based on the individual’s Body Surface Area (BSA). BSA does not apply if more than 1 kg of breast tissue will be removed in each breast.
To view Cigna’s breast reduction surgery Medical Coverage Policy and list of pre-authorization document requirements, visit: Cigna Breast Reduction Medical Coverage Policy (PDF)
Does Kaiser Permanente pay for breast reduction surgery?
Yes. Kaiser Permanente will cover breast reduction surgery.
To view Kaiser Permanente’s breast reduction surgery policy and list of pre-authorization document requirements, visit: Kaiser Permanente Breast Reduction Surgery Overview
Does Aetna pay for breast reduction surgery?
Yes. Aetna will cover breast reduction surgery when a member with macromastia medically documents at least two persistent symptoms for at least a one-year period: Headaches, neck pains, shoulder pain, upper-back pain, painful kyphosis, pain from bra straps, skin pain and soft-tissue damage, and upper extremity parasthesia.
Candidates must submit photographic support confirming severe breast hypertrophy; and medically demonstrate that there’s a reasonable likelihood the symptoms are primarily due to macromastia, and that a breast reduction surgery would result in a positive outcome. Candidates must show that symptoms of macromastia persist despite effort to try other therapeutic measures over a 3-month period.
Aetna requires that women over the age of 50 years old, have a mammogram with a negative cancer screening within 2 year prior to the breast reduction surgery.
To view Aetna’s breast reduction surgery policy and list of pre-authorization document requirements, visit: Aetna Breast Reduction Surgery and Gynecomastia Surgery
Does Humana pay for breast reduction surgery?
Yes. Humana Medicare Advantage plans cover medically necessary breast reduction surgery. As a reminder, Medicare Advantage plans act as Original Medicare including both Medicare Part A and Medicare Part B.
Testing Non-Surgical Options First: Path to Medicare Approval of Breast Surgery Reduction
For back and shoulder pain, the breast reduction surgery candidates must demonstrate relatively exhaustive non-surgical attempts to alleviate and manage symptoms using: supportive garments and back braces; massages and other conservative treatments of acute and chronic back pains; Medicare approved physical therapy, and weight loss and obesity management programs.
In circumstance where the oversized breasts restrict a woman’s activity due to arthritic changes to her upper thoracic spine or cervical spine, she must show ongoing signs of Torticollis (twisting of the neck that makes a person’s head rotate and tilt at an unnatural angle), Cervicalgia (sharp neck pains caused by specific movements), Kyphosis (forward rounding of the upper back), and signs of Ulnar Paresthesias (elbow or wrist pain, claw-like hand curing).
Medicare Defined Signs and Symptoms of Medically Necessary Reduction Mammaplasty
Medicare considers breast reduction surgery medically necessary when skin infections and deformation are caused by the is chronic rubbing, moisture, and lack of air circulation within the breasts. These conditions can be caused by skin-to-skin contact and rubbing. Bras and other support garments like back braces can also create the same physically debilitating disruptions to everyday living.
Cases of Mastectomy Breast Reconstruction: Medicare Pays for Breast Reduction Surgery
For breast cancer patients who undergo a mastectomy surgery, it is common for a reduction mammaplasty procedure to either reconstruct the breasts or improve the symmetry caused by either a single or double mastectomy procedure. Under the Women’s Health and Cancer Rights Act of 1998 (WHCRA), women who elect to have breast reconstruction following a mastectomy will be covered for all stages of reconstruction where the mastectomy was performed.
This includes surgery on the opposite breast to achieve a balanced and symmetrical appearance, any prostheses (breast implant) and any treatment of physical complications caused by the mastectomy. In other words, Medicare covers all medically necessary healthcare treatments associated with breast cancer, including a single mastectomy, double mastectomy, and any breast reconstruction or breast prosthesis surgery following.
In the simplest of Medicare coverage terms, Medicare Part A (hospital) pays for inpatient breast cancer surgery, and Medicare Part B (medical) pays for outpatient surgery and treatment such as breast reduction surgeries. More specifically, Medicare Part A covers breast reduction surgeries after a mastectomy, if the reduction procedure is conducted in an inpatient setting like a hospital. Medicare Part B pays for the reduction surgery if it’s performed in an outpatient setting like a doctor’s office.
Oversized Large Breasts Cause Chronic Physical and Emotional Pain
There are many social stigmas and shameful misconceptions associated with macromastia and secondary health conditions caused by abnormally large breasts. In fact, it’s common for the social norms to create embarrassment and ultimately prevent women from understanding available Medicare benefits that afford reprieve. Wanting to “look good” and taking care of one’s own health are not always different.
Living a productive life free of chronic pain and limitations to performing everyday activities caused by macromastia and other breast-related conditions is important to Medicare. Medicare pays for breast reduction surgeries with a doctor’s pre-authorization that attest and documents the medical necessity.
How Can I Determine If I Am a Candidate for Breast Reduction Surgery?
There are a few key factors that will help determine whether or not you are a candidate for breast reduction surgery. First, your insurance company may have specific requirements that must be met before they will cover the procedure. For example, many insurance companies require that patients have an assessment with a mental health professional to confirm that the surgery is medically necessary. Additionally, you will need to meet certain physical criteria, such as having breast tissue that is significantly above the crease of your breast. Finally, you should be prepared to commit to making lifestyle changes, such as quitting smoking and avoiding pregnancy, as these can impact the results of your surgery. If you are considering breast reduction surgery, be sure to discuss your candidacy with a qualified surgeon.
What Are The Benefits Of Breast Reduction Surgery?
The most common type of breast reduction surgery is the “inferior pedicle” method, which removes skin and breast tissue from underneath the nipple-areola complex, preserving the natural attachments of the areola and nipple to the underlying breast tissue. The inferior pedicle method delivers a smaller breast with an elevated nipple-areola complex.
Other types of breast reduction surgery include the “superior pedicle” method, in which skin and breast tissue are removed from above the nipple-areola complex; the “central pedicle” method, in which skin and breast tissue are removed from around the nipple-areola complex; and free nipple grafting, in which the nipple-areola complex is completely detached from the underlying breast tissue and grafted into its new position. Your Medicare-approved plastic surgeon should recommend the best type of breast reduction surgery for you based on your individual anatomy and desired outcome.
• Breast reduction surgery can help alleviate back, neck, and shoulder pain.
• It can also improve your ability to participate in physical activity.
• The surgery can also lead to improved self-esteem and body image.
• Breast reduction surgery can also help reduce the risk of developing breast cancer.
• Breast reduction surgery is a safe and effective procedure with a high success rate.
• The recovery from breast reduction surgery is usually quick and relatively painless.
Breast Reduction Procedure
For many women, large breasts can be a source of physical and emotional discomfort. In addition to causing back pain and neck strain, large breasts can make it difficult to find clothes that fit well and can lead to self-consciousness and insecurity.
Breast reduction surgery is a way to address these concerns by reducing the size of the breasts. The procedure involves removing excess skin and tissue from the breasts, and it can also involve moving the nipple and areola to a new position. In some cases, breast reduction surgery can be done using liposuction alone, but in other cases, incisions will need to be made.
After the surgery, patients will need to wear a special surgical bra and will likely experience some pain and swelling. Physical therapy may be recommended to help with healing, and patients will also need to take prescription medication for pain relief. For most women, breast reduction surgery provides significant relief from the physical and emotional discomfort of large breasts.
How Long Does The Average Breast Reduction Surgery Take To Recover From?
For many women, breast reduction surgery is a life-changing experience. Not only does it help to improve their physical appearance, but it also helps to alleviate pain and discomfort. However, as with any surgery, breast reduction comes with some risks and side effects. The good news is that most women are able to recover from breast reduction surgery fairly quickly. In most cases, the surgery itself takes less than two hours to complete. However, recovery times will vary depending on the individual.
In general, most women will need to take at least one week off from work or other strenuous activities in order to fully recover. Additionally, there is usually some pain and swelling during the first few days after surgery. However, this can be controlled with medication. Overall, breast reduction surgery is a safe and effective way to improve your quality of life.
Are There Any Risks Associated With Breast Reduction Surgery?
Breast reduction surgery is a major procedure that comes with a number of potential risks. These risks can be broadly divided into two categories: those associated with the surgery itself and those associated with the woman’s individual health. In terms of surgery, the most common complications include bleeding, infection, and poor wound healing. There is also a risk of damage to the nerves that provide sensation to the breast. As a result, some women may experience numbness or reduced sensation in the operated area.
In terms of the woman’s individual health, there is a small risk that the breast cancer diagnosis may be delayed or missed due to the removal of breast tissue. There is also a risk that future breast reconstruction may be more difficult. However, it is important to remember that breast reduction surgery is generally safe and effective and that the risks associated with the procedure are relatively rare.
What Will My Breasts Look Like After Breast Reduction Surgery?
Breast reduction surgery is a popular cosmetic procedure that can help to reduce the size of overly large breasts. The surgery involves making incisions in the breast tissue and then removing excess skin, fat, and glandular tissue. In some cases, the surgeon may also need to reposition the nipple or areola. Most patients who undergo breast reduction surgery are able to return home the same day.
After the procedure, patients will typically wear a surgical bra and will have drains placed in their breasts to help remove any fluids that may build up. In the weeks following surgery, patients may experience some bruising, swelling, and discomfort. However, these side effects should gradually improve as the body heals. Ultimately, most patients are very happy with their results and find that their quality of life has significantly improved. For many women who have struggled with overly large breasts, breast reduction surgery is a life-changing experience.
How Much Does Breast Reduction Surgery Cost?
A breast reduction surgery is a cosmetic procedure to remove excess breast tissue and skin to achieve a breast size in proportion with the body. The average cost of the surgery is $5,000, but it can range from $3,000 to $10,000 depending on the surgeon’s fee, the facility where the surgery is performed, and the extent of the procedure. Health insurance may cover some or all of the costs if the surgery is considered medically necessary. Some factors that contribute to the cost of breast reduction surgery include the surgeon’s fee, the facility where the surgery is performed, and the extent of the procedure.
A plastic surgeon’s fee includes preoperative consultations, surgical fees, and post-operative care. You may find the ‘facility fee’ includes operating room charges, equipment rental, and other miscellaneous expenses. The extent of the procedure will also affect the cost; a more complex surgery will take longer to perform and require more anesthesia and surgical supplies. Insurance companies typically consider breast reduction surgery to be medically necessary if it is performed to alleviate pain or physical discomfort associated with large breasts.
However, some policies have exclusions or limitations on coverage for cosmetic procedures. It is important to check with your insurance provider beforehand to see if your policy covers breast reduction surgery.
If you are considering breast reduction surgery, be sure to consult with a board-certified plastic surgeon to discuss your goals and expected results. The surgeon will be able to give you an estimate of the cost of the procedure based on your specific case.
What Is An Ambulatory Surgery Center And What Does It Cover?
An ambulatory surgery center, or ASC, is a type of outpatient surgical facility that provides a wide range of surgical procedures. Unlike a hospital, an ASC is not equipped to handle emergencies or complex surgeries. However, an ASC can provide many of the same services as a hospital, including diagnostic testing, minor surgery, breast surgeries, and pain management. In addition, an ASC typically has shorter wait times and lower costs than a hospital. As a result, an ASC is often the preferred choice for patients who need to undergo elective or minimally-invasive surgery.
Does Medicaid Cover Plastic Surgery For Breast Reduction?
While Medicaid does cover a wide range of medical procedures, it does not typically cover cosmetic surgery. This includes procedures such as breast reduction, which is considered to be elective surgery. There are some exceptions, however, such as when the procedure is medically necessary to correct a birth defect or to treat a medical condition such as breast cancer. In those cases, Medicaid may cover part or all of the cost of the surgery. Individuals who are considering plastic surgery should check with their Medicaid provider to see if their procedure will be covered.
Is Financing Available For Breast Reduction Surgery?
Breast reduction surgery is a popular and effective way to reduce the size of large breasts. However, the procedure can be expensive, making it difficult for some patients to afford. Fortunately, there are several financing options available to help cover the cost of breast reduction surgery. Many surgeons offer in-house financing plans with affordable monthly payments.
In addition, most major credit cards offer medical financing options with low interest rates. There are also a number of medical loans available from banks and other lenders. By doing some research and exploring all of the options, it is possible to find a financing plan that works for you and your budget. With the help of financing, breast reduction surgery can be within reach for almost anyone.
Common Questions About Breast Reduction Surgery and Medicare Coverage
• Will Medicare pay for my breast reduction surgery?
• How Do I Get Predetermined and Preauthorized for Breast Reduction Surgery?
• What are the non-surgical requirements before Medicare approves breast reduction surgery?
• Does Medicare cover breast reconstructive surgery after a mastectomy?
• How can I determine if I’m a candidate for breast reduction surgery?
• Does My Medicare Insurance Company Cover Breast Reduction Surgery?
• Does UnitedHealthcare pay for breast reduction surgery?
• Does Humana pay for breast reduction surgery?
• Does Blue Cross Blue Shield pay for breast reduction surgery?
• Does Aetna pay for breast reduction surgery?
• Does Kaiser Permanente pay for breast reduction surgery?
Cited Sources of Research for Breast Reduction Surgery Medicare Overview:
CMS: Reduction Mammaplasty Overview and Recommendations by CMS
National Health Institute: Navigating the Insurance Landscape for Coverage of Reduction Mammaplasty
National Health Institute: Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?
TrustMedicare: Compare Medicare Advantage Plans
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