Will Medicare Pay for Unilateral Breast Reduction?

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

Doctor Answers (9)

Medicare and Unilateral Breast Reduction

+2

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 accepting Medicare patients. This increases the stress on those who do and patients who depend on Medicare for their care.

Unfortunately, the medical establishment does not view large breasts as a dire medical condition which must be corrected and it throws every possible barrier in your path. Breast asymmetry is treated even worse as it is viewed as a cosmetic condition.

Unless you are willing to take charge and get your Medicare policy approve a breast reduction on the large side you will find that many surgeons will shy away from doing so. They simply do not have the staff hours to get it approved and many cannot afford performing this surgery at the rates Medicare will pay, should miraculously formally approve the surgery.

Sorry for the glum answer. But you have the right to know where you stand.


Memphis Plastic Surgeon
5.0 out of 5 stars 66 reviews

Medicare and breast reduction surgery coverage

+1

Medicare will only pay for a surgery that it deems medically necessary.  There is no pre-approval process with Medicare.  We call it Las Vegas, roll the dice and see if they pay. All that we can do as physicians is to document the problem as with any other patient and try to meet the same criteria as any other insurance company.  Unfortunately with Medicare it is only in retrospect that Medicare determines eligibility.  If they deny payment then they could not only deny payment to the physician but to the hospital as well.  Not a good workable situation for anyone involved.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 10 reviews

Medicare Coverage Of Unilateral Breast Reduction

+1

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 Medicare does not cover the procedure after it is done.

I hope this helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 793 reviews

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Medicare paying for breast reduction

+1
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
5.0 out of 5 stars 12 reviews

Medicare Will Sometimes Cover Breast Reduction

+1

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
5.0 out of 5 stars 2 reviews

Medicare Breast Reduction

+1

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 if medicare denies it.

Regafds,

Daniel Medalie, MD

 

Daniel A. Medalie, MD
Cleveland Plastic Surgeon
5.0 out of 5 stars 14 reviews

Will Medicare Pay for Unilateral Breast Reduction?

+1

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
4.5 out of 5 stars 64 reviews

Medicare breast reduction

+1
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
4.5 out of 5 stars 21 reviews

Medicare and Breast Reduction

+1

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.

Miguel Delgado, Jr., MD
San Francisco Plastic Surgeon
4.5 out of 5 stars 35 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.