Will Medicare Pay for Unilateral Breast Reduction?

asked 8 months ago by Alex911 in Tiverton, RI
Latest answer by Tom J. Pousti, MD
Question viewed 187 times
Tags: insurance, medicare

I am SP three excisional biopsies of the R breast and one on the L breast. Post sx's my L breast is considerably larger. No bra will fit and I keep getting Muscle spasms in my neck on the L side. I have fibromyalgia and CTCL/MF. Currently my skin becomes irritated secondary to the size disparity regardless of what size bra I wear. V/R Alex 60yo

8 answers to Will Medicare Pay for Unilateral Breast Reduction?

Medicare and Unilateral Breast Reduction

I truly sympathize with your condition but must remind you of the stated purpose of Medicare and where we stand today. I will start with today. Medicare is rapidly running out of money and while there is fraud in the system the vast majority of doctors are frustrated with the huge bureaucracy, thousands of pages of regulations and the way they are treated by the system. Due to poor reimbursements which have not kept up with inflation and increasing hurdles many doctors are no longer... more

Peter A. Aldea, MD
Memphis Plastic Surgeon

Medicare Coverage Of Unilateral Breast Reduction

Thank you for the question. Unfortunately, there is no way to know for sure whether Medicare will cover the surgery in your case. I think your best bet is to work with a board-certified plastic surgeon who does a lot of work with Medicare patients. Gather as much documentation as possible from your primary care/internists regarding the “medical necessity” of the procedure. The plastic surgeon's documentation will also be important in the event that... more

Tom J. Pousti, MD
San Diego Plastic Surgeon

Medicare paying for breast reduction

Unfortunately Medicare does not preauthorize surgery so there is no way of knowing ahead of time whether they will pay for it. I personally have been skunked by Medicare on breast reductions which I felt were clearly indicated, but other plastic surgeons may have different experience with this. I would consult a few platic surgeons but it is likely you will have to pay for the operation yourself.

Ronald J. Edelson, MD
San Diego Plastic Surgeon

Medicare Will Sometimes Cover Breast Reduction

Medicare may or may not cover breast reduction surgery. The problem is that MediCare will not preauthorize any surgery, including breast reductions. A sgnificant amount of tissue would need to be removed in order to have it covered. There must also be documented symptoms for which conservative treatment has not succeeded.

John Whitt, MD
Louisville Plastic Surgeon

Medicare Breast Reduction

There are many plastic surgeons who perform breast reductions on medicare patients. The real problem is that medicare does not accept pre-determination letters and thus you can never be sure that they will cover the procedure. They may deny payment after the surgery because the volume removed was not sufficient enough to constitute a medical necessity. You will need to discuss this with your plastic surgeon and be ready to sign a release acknowledging that you may have to pay for the surgery... more

Daniel A. Medalie, MD
Cleveland Plastic Surgeon

Will Medicare Pay for Unilateral Breast Reduction?

Agree with Dr Aldea, Medicare is in trouble. Best to try and find a boarded PS to accept medicare and write a predetermination letter.

Darryl J. Blinski, MD
Miami Plastic Surgeon

Medicare breast reduction

Medicare will generally cover a breast reduction of one or both breasts if the amount removed from each breast is over 500 gms. Sometimes they will also cover an equalizing mastopexy (reduction of one side) for cancer patients. I would check with your plastic surgeon to find out what his experience has been.

Robert M. Jensen, MD
Medford Plastic Surgeon

Medicare and Breast Reduction

It will probably be very difficult to get medicare to cover your surgery, but even more difficult will be to find a surgeon willing to do the surgery as medicare reimbursement is very low. If you do find a surgeon that is willing, his office would help you submit for pre-authorization. If you have a university in your area that has a teaching medical school, you might try contacting them as many times you can get surgery by a resident closely supervised at a reduced cost. Good luck. more