Does Medicaid require medical documentation for a breast reduction?

Question

Do I need to have documentation of back pain, etc. from my physician for Medicaid to deem it medically necessary before seeing a plastic surgeon or can I skip the physician and go straight to the plastic surgeon and Medicaid still cover it?

James N. Romanelli, MD, FACS · Answer

Thank you for your question. Different states have different guidelines for Medicaid coverage, and unfortunately, I am not familiar with Louisiana’s regulations. It’s best to check with a local surgeon or with your local Medicaid office. Best of luck.

Edwin C. Pound, III, MD · Answer

Insurance usually considers two criteria when deciding on coverage.  The first is the amount of tissue being removed.  Insurance companies have charts based on your height, weight, and body surface area that they use to determine how much tissue needs to be removed in order to warrant coverage.  The second thing they consider is functional issues related to your large breasts, such as back, neck, shoulder strain, breakouts under the fold of the breast requiring medication, etc.  Insurance companies often require a letter from a chiropractor as well as a plastic surgeon.  If you can get letters advocating breast reduction from other physicians, it helps to influence the insurance company to cover you.

Susan MacLennan, MD · Answer

Hello-Each state will have different criteria for covering breast reduction under Medicaid. You may be able to contact your state's Medicaid program (is there a phone number on your card?) and ask them if they have specific criteria. It would be very helpful to your plastic surgeon if you came in for your consult with any documentation that might be required by Medicaid. This might include documentation from your family doctor, physical therapist, etc. It is also possible that your state Medicaid program may require a referral from your doctor to the surgeon. Best to try to find this out ahead of time so that the process is smooth for you.Best wishes-

Does Medicaid require medical documentation for a breast reduction?

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