Medicaid Coverage for Breast Reduction of a C and Dd Cup Breasts?

My right breast is DD and my left a C. I've struggled with this for 8 years. Doctors said they would catch up around when I turned 18 but they didn't and when I got pregnant the difference got worse; with the milk and then when it went away.

And now I'm having back pain, shoulder blade pain, and neck pain, and my skin underneath is off and on irritated, dry, peeling and theres red lines sometimes. And my sleeping is affected. I'm in desperate need of a Breast Reduction. But I don't know what to do with my insurance.

Doctor Answers (6)

Insurance

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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


Houston Plastic Surgeon
4.5 out of 5 stars 115 reviews

Medicaid Coverage for Breast Reduction of a C and DD Cup Breasts

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The requirements for bilateral breast reduction coverage by Medicaid have always been so rigid as to make it almost impossible to have them agree to cover the procedure.  If you could get it approved it will be hard to find a plastic surgeon to accept the fee that Medicaid pays for this procedure.

Paul Vitenas, Jr., MD
Houston Plastic Surgeon
5.0 out of 5 stars 37 reviews

Breast Reduction and Medicaid?

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Thank you for the question.

Medicaid has been known to cover breast reduction surgery. For multiple reasons,  most plastic surgeons that I know of to not work with Medicaid. I think finding a reputable plastic surgeon who will work with Medicaid will be the challenge you will face.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 703 reviews

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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
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Insurance coverage for breast lift or breast reduction.

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Insurance Coverage for 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.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Medicaid Breast Reduction

+1

Medicaid will likely cover the procedure. Your problem may be finding a surgeon who will be willing to accept this as payment in full. It is quite difficult for surgeons to cover the costs of running their practice when reimbursed at these low rates.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 43 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.