Will medicare pay towards a breast reduction? I wear a triple ddd have had shoulder and back pain for years

Doctor Answers 7

Medicare and breast reductions

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Breast reduction is considered a medical necessity when the patient can document physical symptoms, such as neck/back pain, shoulder grooving, and postural changes.  Most insurances require a pre-authorization, which involves submitting photos and supporting documentation first to get approval.  

With Medicare you cannot do that, since they do not do preauthorizations.  You should have the symptoms documents by your physician or gynecologist, as well as the board certified plastic surgeon.  If the surgeon feels that there are medical indications, they can proceed with surgery.  You will have to sign a waiver, so that if ultimately medicare denies the surgery as cosmetic, you will be responsible for the surgical fees.

Long Island Plastic Surgeon
5.0 out of 5 stars 19 reviews

Will medicare pay towards a breast reduction?

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Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we perform.
Based on your description you may be a good candidate for breast reduction surgery. You will do best achieving a long-term stable way prior to proceeding. The best way to obtain "insurance coverage" for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. This documentation and letter/pictures from your plastic surgeon will help you obtain authorization.
You may find that working with Medicare  that you will not be able to obtain “preauthorization”.
Make sure you are  working with a well-trained/experienced board-certified plastic surgeon who can demonstrate significant experience achieving the types of outcomes you will be pleased with.  
Best wishes.

Medicare and Breast Reduction

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The costs for #BreastReduction varies by the following:
Surgeon's expertise and experience
The cost for anaesthesia and operating facility
The geographic location you have the procedure
Estimates can be obtained here on RealSelf , PlasticSurgery.org or Surgery.org
Although, #BreastReduction procedures are commonly covered by #insurance and required criteria, it is becoming more and more restrictive. Some practices do not accept insurance. However, ask the staff to assist you in obtaining pre-authorization so that you can attempt to be #reimbursed for out of pocket #expenses.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

Insurance and BR

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From your description it seems as if you are a good candidate for breast reduction. Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). 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. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Medicare breast reduction

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The big problem with Medicare breast reductions is that the process does not allow a surgeon to get a pre-authorization for it as other insurance companies do.  So, the patient has no promise pre-operatively that the surgery will get covered.  It can be a big gamble.  You have to have all the documented symptoms and document that you have gone through conservative measures to get relief from those symptoms such as taking ibuprofen for back pain for 6 months.  Your surgeon also has to chart out your body weight, height, and likely weight of the tissue to be removed during your reduction (based on your physical exam).  Modest reductions (even if they help a patient functionally) will not get covered no matter what your symptoms are.

Due to the gamble without the preauthorization, many of us will only do very large reductions with documentation of symptoms and treatment to try to assure payment by Medicare.  Even with all of that, there is no promise that Medicare will come through and the patient may be stuck with a bill.  That is why many patients will opt to control their costs by going the self pay route and doing the surgery as an outpatient in a surgery center. 

I have attached the criteria for consideration for breast reduction coverage below.  Thank you for your question!

Breast reduction

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If you can't it may be worth while looking into the liposuction only reduction. It is less expensive, quick, outpatient procedure with minimal aftercare and down time. Doesn't work for everyone so find a BCPS in your area who specializes in the Scarless reduction and look into it.

Sherwood Baxt, MD
Paramus Plastic Surgeon

Medicare breast reduction

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If the reduction is to improve quality of life and it meets their requirements as far as the amount of tissue removed, it should be covered. The issue is finding a good surgeon who will accept the minimal payment that Medicare offers. A breast reduction is a significant  amount of work and most surgeons want to be compensated fairly for their effort.

You may do better to have the surgery done by plastic surgery residents at a teaching hospital. Be sure the attending surgeon is involved. You should do well as this is the type of case that is done often.

Best of Luck

Dr. J

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.