Medicare primary 66 yrs old female wanting Breast Reduction. Fed blue cross blue shield 2 nd dairy. Any suggestions? (photos)

Medicare doesn't precertified for breast reduction on seniors. I have fed blue cross blue shield secondary. How do I proceed or get staff to navigate Medicare then my secondary.

Doctor Answers 4

Medicare primary 66 yrs old female wanting Breast Reduction. Fed blue cross blue shield 2 nd dairy. Any suggestions?

I suggest getting documentation by your plastic surgeon, have him or her submit photo's and a request for authorization with procedure plan so it is documented pre-operatively. Judging from your picture I feel strongly your surgery will be covered. If in the unlikely event it is denied, your out of pocket costs for the surgery , anesthesia, and operating room would be $9,500.

San Francisco Plastic Surgeon
4.4 out of 5 stars 7 reviews

Medicare primary 66 yrs. old female wanting Breast Reduction. Fed Blue Cross Blue Shield secondary.

You are correct, it can be confusing and intimidating trying to get pre-authorization for breast reduction surgery.  Although, I am not an expert on negotiating the pre-authorization process; my business manager, Leann Clinton, is.  You can call my office and ask my receptionist if she can put you in touch with Leann.  Tell Leann, I responded to your question and asked that she help give you guidance.  Best wishes, Dr. Lepore.

Vincent D. Lepore, MD
San Jose Plastic Surgeon
4.9 out of 5 stars 49 reviews

Medicare & breast reduction

Hi there, great question!  It is unfortunate that we can’t get Medicare to pre-authorize surgeries.  However, if you see a board certified plastic surgeon, her or his office staff should have people in place who are experts at navigating the insurance companies.  We often have a good idea on what Medicare may or may not cover.  I am always honest with my patients if I feel they will not meet Medicare eligibility requirements for any surgery.  See your surgeon to get the process started & good luck!Sincerely,Dr. Michelle Spring

How to Get Medicare Coverage for Breast Reduction

You cannot get pre-authorization from Medicare for breast reduction. You only know if they will pay after you have submitted the claim. If they deny the claim you have to cover the entire expense. Therefore you have to follow the LCD, local coverage determination, criteria that Medicare requires for documentation BEFORE you have the surgery. There are specific criteria for coverage which include having certain symptoms like back or neck pain, skin problems and interference with activity.  Others include evaluation by a doctor for endocrine abnormalities, and failed therapeutic attempts like physical therapy, support bras, etc.  Your weight and body surface area and Schnur scores have to be calculated and the expected reduction in grams removed stated. All of this has to be documented in advance and submitted along with the claim. Also you can look up the coverage criteria in the medical necessity section f the website of your secondary blue cross/blue shield carrier.

Robert M. Lowen, MD
Mountain View 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.