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Will Medicaid Cover Breast Reduction for H Cup Breasts?

I am 26 yrs from New Orleans and am on medicaid. I've been to the doctor several times for my back and breasts. My right breast is longer than my left breast and I've got 48H cup breasts and weight 223 lbs with a height of 5'1".

My back hurts when I sit and stand for a long time. Do you think medicaid will pay for me to get a Breast Reduction?

Doctor Answers (11)

Insurance coverage for breast reduction

+1

I'm not familiar with Medicaid but can comment on private insurance.  Breast reduction may be covered by insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.


Houston Plastic Surgeon
4.5 out of 5 stars 36 reviews

Breast reduction

+1

Medicaid will probably pay for the reduction, but the larger concern is your weight. You are 100lbs overweight, which increases the risk of any elective operation. I would suggest you look into physician assisted weight loss for your general health. After losing 50-100lbs, then you may not need a reduction, and your overall health will be better.

Gregory Sexton, MD
Columbia Plastic Surgeon
5.0 out of 5 stars 27 reviews

Breast Reduction - Insurance Coverage

+1

Probably, but you cannot assume that and, regardless, there are still some issues. And they may not approve it for you right bnow.

Each insurance company is different, and each has its own rules with respect to "coverage."  It used to be that a 500 gram reduction (from each side) would be enough to qualify for insurance coverage, but that is no longer the case and cannot, in any event, be assumed to be the case. You'll first have to contact your company to make sure it's covered, and then you have to find a surgeon who will accept the payment the insurance company says is "usual and customary."  That may or may not be easy to do.  If you start with the surgeons who participate in the insurance company you'll be off to a good start.  If you'd rather use a different surgeon, and you have out-of-network benefits, you can contact the surgeon's office and see if he/she will accept that payment.

The insurance company may also ask you to lose weight and/or try conservative therapy before making a determination.  In your case, since you weigh 223 pounds and are 5' 1" tall, you should undergo significant weight loss before considering this surgery as that is undoubtedly a contributing factor to your pain and, furthermore, the risks of this surgery are much in people who have  BMI (Body Mass Index, which generally addresses obesity and the relative contributions of your height and weight) as high as yours is.  Yours is 42.1; anything over 30 is considered obese and increases the risks of surgery.

Then, you'll need the help of a plastic surgeon to submit a letter of precertification (typically including your height, weight, bra size, specifics of any pain that you have and how your enlarged breasts affect your health and quality of life) and photos and to make sure that everything is set before you have the surgery.

I hope that this helps and good luck,

Dr. E

Alan M. Engler, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 148 reviews

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Medicaid coverage for gigantomastia

+1
Breast reductions for H cup breasts are almost always approved with one caveat-if your insurance plan restricts coverage to women with body mass indices below a certain cutoff point, it could be denied based upon your weight. I find this requirement applicable to many HMOs but, again, there may be an exception because of the extremely large size of your breasts.

Robert L. Kraft, MD
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Breast Reduction Insurance Coverage?

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Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.

Based on your description you may be a good candidate for breast reduction surgery; for  physical and emotional reasons.
The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.
 

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
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Insurance and breast reduction

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Each insurance carrier has different criteria for pre-approval of a breast reduction. You should check with your insurance carrier.

Steven Wallach, MD
Manhattan Plastic Surgeon
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Breast Reduction Under Insurance

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Medicaid may cover this surgery but there needs to be a preoperative authorization obtained. You may or may not qualify just depends on what their requirements are.

That is not so much an issue but finding a qualified plastic surgeon that would be willing to undertake this huge operation under medicaid payment. This surgery is already underpaid by PPO health insurance and others. Medicaid payment would even be lower than others and most qualified board certified plastic surgeons do not do any surgeries under medicaid for that reason.

You may have some luck with the county teaching hospitals where residents are supervised to perform these surgeries. You may want to check with your local county hospital.

Good luck.

Farbod Esmailian, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 31 reviews

Insurance coverage for breasts reduction surgery

+1

Medicaid coverage will vary greatly from state to state.  There may also be a weight requirement.  Many times we find that Medicaid and other insurance companies require an attempt at weight loss and other non surgical modalities to see if this gives any pain and symptom relief. 

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 8 reviews

Medicaid Coverage of Breast Reduction

+1

Each state decides on their criteria for coverage of different procedures by Medicaid. I agree with others that you will have difficulty finding a private practice plastic surgeon willing to perform the procedure because of the ridiculously low reimbursement for this big operation. Your best bet is probably to try to obtain a consultation with either the LSU or Tulane Plastic Surgery Depeartment. Good Luck!

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Louisiana Medicaid coverage for H cup Breast Reduction

+1

Every state Medicaid program has its own requirements and quirks. Our colleagues in Louisiana would be your best source for finding out if your operation will be paid for by them or not.

IF your state is anything similar to Tennessee, be prepared for the following.
1. Very few Plastic surgeons accept Medicaid (in our state TennCare) because of the extremely low payments and the large numbers of hurdles both patient and surgeons have to jump over.

2. There may be a requirement that you be of a certain weight, from your height and weight, you have a Body Mass Index of 42 kg/sq meter which makes you morbidly obese (Your IDEAL body weight is 106 pounds - less than half your current weight). They may well mandate that you lose a lot of weight before approving your operation.

Good Luck.

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 58 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.