How to Qualify for Medicaid for Breast Reduction?

Question

Ok I just had a baby, and my medicaid ran out. They say its very hard to get it back once it runs out because its hard to prove you have a condition. Is there any way I can get Medicaid easier? How do I prove I'm having these neck and back pains? How do I qualify for the procedure?Can I get a Breast Reduction and they still look perky and full? Do you think it's time for a Breast Reduction?

Donovan Rosas, MD · Answer

Each insurance provider will have different requirements for approval of reduction surgery. Generally speaking, one must pre-operatively document a medical necessity for surgery and failure of more conservative options including physical therapy, medical therapy, weight loss. Post operatively, your surgeon must document adequate tissue removal (often based on Body Surface Area-BSA and the Schnur Scale). This is often a minimum of 500 gms per side.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Jed H. Horowitz, MD, FACS · Answer

Breast Reduction: insurance coverage benefitsYou certainly look as though you would benefit from a #breastreduction. In general when the
excessive breast size causes functional problems, insurance will generally pay
for the operation if more than 400 – 500 grams are removed from each breast
dependent on your individual insurance company requirements. These problems may
include neck pain, back or shoulder pain, hygiene difficulty, and breast pain.
Medical is very difficult unfortunately

Sheila S. Nazarian, MD · Answer

Breast reduction, or reduction mammaplasty patients are among the most satisfied of all plastic surgery patients. Large breasts (macromastia) can often decrease quality of life for a woman. With breast reduction, you can have smaller breasts that sit higher on your chest wall. You will also find relief in your neck and back with the decrease in weight and more ergonomic position of your breasts.There are several different variations of breast reduction, differing by size, and amount of incisions; procedure; and the results. The different types of reduction techniques include: The wise pattern breast lift, the anchor shaped incision, and the donut mastopexy.1. The wise pattern breast lift involves an anchor-shaped incision around the natural contour of the breast. To most patients surprise, this scar is mostly hidden under the inferior aspect of the breast. However, the scar around the nipple/areola is visible. Most patients heal this anchor type scar very well and are satisfied with smaller areola in exchange for the scars. This surgery is used when there is a lot of excess skin that needs to be removed in order to lift the breast and give it a more aesthetic shape.2. Often times, the anchor shaped incision can me diminished to create a lollipop or J shaped incision. This results in some excess skin at the inferior aspect of the breast near the breast crease that will flatten out over a 6 month period. Some patients are willing to tolerate this excess skin for 6 months in exchange for a smaller scar. This is a personal decision that each patient can make.3. The donut mastopexy involves creating an incision around the areola and removing a doughnut-shaped area of skin. This surgery can be used for patients that need a smaller amount of lifting. This surgery results in a scrunched-up look to the breast skin surrounding the areola for about 6 months before it flattens out. Patients need to be understanding and tolerant of this in exchange for an areola-only scar. These patients do run the risk of areola widening as well.Insurance may cover some of these cases when back pain, shoulder bra-notching, and rashes under the breast are present. Insurances vary though and your doctor can submit a report and photos to see if your insurance approves your procedure.The ideal size depends on the size of your hips and waist.  Your surgeon will be able to guide you in this decision.The risks of the procedure include bleeding, infection, bruising, poor scarring, pain, swelling, and changes to nipple and areola sensation, and rarely, partial or total nipple loss. The recovery time is usually a couple weeks if all goes well. In general, however, breast reduction patients are some of the most satisfied and grateful plastic surgery patients. This is truly a life-changing procedure. In my area, the cost ranges from 6700-8500. Best of luck!

Otto Joseph Placik, MD · Answer

Perky and full is not a realistic outcome following breast reduction in your particular instance. As Dr. Rand has discussed, it is highly unlikely that most plastic surgeons in private practice would be willing to accept Medicaid. However, seeking care at a University Hospital is more reasonable option.

Leo Kim, FRACS(Plast), MS(Plast), MBBS(Hons) · Answer

In Australia if your private health insurance covers the breast reduction item numbers your hospital and operating theater costs will be covered. The only "out of pocket" is for surgical fee and anaesthetic fee and this can be between $6-10,000.
Wish you the best in your journey,
Dr Leo Kim, Specialist Plastic Surgeon in Sydney

C. Bob Basu, MD, MPH, FACS · Answer

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

Tom J. Pousti, MD · Answer

Thank you for the question and picture.
 Yes, I think you are an excellent candidate for breast reduction surgery.
 I think the biggest challenge  you will have is finding a reputable plastic surgeon who works with Medicaid.
 Best wishes.

Steven Wallach, MD · Answer

You should first check with Medicaid to determine what their cirteria are. Then see a plastic surgeon. You may also need notes from a treating physician for back pain and neck pain.

Pat Pazmino, MD, FACS · Answer

Our breast reduction patients are some of our happiest patients. They appreciate their new look and literally have had a significant weight taken off their shoulders. As you know, some insurance policies may cover this procedure. However, it depends on the insurance policy and the insurance company. In our practice, we have seen many insurance companies do everything possible to avoid paying for medically necessary procedures such as a breast reduction. If you are not able to have your breast reduction covered by an insurance company, work with a board-certified plastic surgeon who has a great deal of experience in breast reduction and breast contouring and inquire about financing plans. In our practice, our patient coordinators are experts at finding a plan that will fit the patient's budget.

Darryl J. Blinski, MD · Answer

I must agree with the previous expert posters. First, get a Medicaid coverage / card. Then TRY and find a boarded Plastic surgeon and hospital that accepts Medicaid. If you cannot, then by all means go to a local university hospital to the division of Plastic Surgery for this operation. Best of Luck.

How to Qualify for Medicaid for Breast Reduction?

Answers (15)

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