How to Qualify for Medicaid for Breast Reduction?

Ok I just had a baby, and my medicaid ran out. They say its very hard to get it back once it runs out because its hard to prove you have a condition. Is there any way I can get Medicaid easier? How do I prove I'm having these neck and back pains? How do I qualify for the procedure?

Can I get a Breast Reduction and they still look perky and full? Do you think it's time for a Breast Reduction?

Doctor Answers 11

Insurance coverage for breast lift or breast reduction.

Answer by George J. Beraka, MD
Manhattan Plastic Surgeon
80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2) Very big reductions (like from an F cup to a C cup) will usually be covered.

3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9) Don't give up. If the first request is denied, demand an appeal.

10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.

Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Insurance coverage

Every insurance plan has their own unique criteria on whether they will cover a breast reduction.  More and more, we are seeing plans where a breast reduction is not a covered benefit.  If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage.  Some set the amount in relation to your BMI (height and weight).  Others require extensive medical records documenting neck pain, back pain, and history of rashes.   The other alternative is to opt for a breast reduction as a self-pay option.   Start by visiting with a board certified plastic surgeon to learn more about your options.
Best wishes,

Dr. Basu
Houston, TX

Breast Reduction and Medicaid?

Thank you for the question and picture.

Yes, I think you are an excellent candidate for breast reduction surgery.

I think the biggest challenge  you will have is finding a reputable plastic surgeon who works with Medicaid.

Best wishes.

Insurance coverage for a breast reduction

You should first check with Medicaid to determine what their cirteria are. Then see a plastic surgeon. You may also need notes from a treating physician for back pain and neck pain.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 19 reviews

Financing for breast reduction

Our breast reduction patients are some of our happiest patients. They appreciate their new look and literally have had a significant weight taken off their shoulders. As you know, some insurance policies may cover this procedure. However, it depends on the insurance policy and the insurance company. In our practice, we have seen many insurance companies do everything possible to avoid paying for medically necessary procedures such as a breast reduction. If you are not able to have your breast reduction covered by an insurance company, work with a board-certified plastic surgeon who has a great deal of experience in breast reduction and breast contouring and inquire about financing plans. In our practice, our patient coordinators are experts at finding a plan that will fit the patient's budget.

Pat Pazmino, MD
Miami Plastic Surgeon
4.5 out of 5 stars 66 reviews

Qualifying for Medicaid for Breast Reduction

I must agree with the previous expert posters. First, get a Medicaid coverage / card. Then TRY and find a boarded Plastic surgeon and hospital that accepts Medicaid. If you cannot, then by all means go to a local university hospital to the division of Plastic Surgery for this operation. Best of Luck.

Medicaid Coverage of Breast Reduction

Perky and full is not a realistic outcome following breast reduction in your particular instance. As Dr. Rand has discussed, it is highly unlikely that most plastic surgeons in private practice would be willing to accept Medicaid. However, seeking care at a University Hospital is more reasonable option.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 55 reviews

Medicaid Breast Reduction

First you need to get Medicaid coverage. You should already know how to do that. I'm not sure why you are not still covered.

Next you need to see you family Dr and discuss any symptoms you might have. They will treat those symptoms or refer you to a plastic surgeon. If you are not having symptoms and just want smaller lifted breasts that is cosmetic and not covered by insurance.

Once in the hands of a plastic surgeon they will guide the process

John P. Stratis, MD
Harrisburg Plastic Surgeon
4.5 out of 5 stars 22 reviews

Breast reduction by medicaid

Probably most plastic surgeons in private practice wouldn't take medicaid because the reimbursement won't even cover their costs to do the reduction.  I would go to the regional university hospital where the plastic surgeons will take care of you regardless of coverage. 

Medicaid coverage of Breast Reduction

From your photo, it certainly appears that you would benefit from a breast reduction. The criteria for both your participation in the program as well as the coverage of the operation varies among states. Another likely problem will be finding a plastic surgeon willing to perform the procedure if it is covered by Medicaid because of their typically very low reimbursement rates. If you live near a medical school, you might check to see if someone there could evaluate you.

John Whitt, MD (retired)
Louisville Plastic Surgeon
5.0 out of 5 stars 2 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.