Has Medicaid ever paid full coverage for a breast reduction?

Question

I called my insurance company and found out I have full coverage Medicaid under Gateway. I hear Gateway is a "crappy" insurance company but I'm hoping my huge breast will reduce the chance of being denied. Do any of you,Dr.s know any client with the same insurance that has successfully been covered? I know its based on medical necessity.

Larry S. Nichter, MD, MS, FACS · Answer

In answer to your second question: will Medicaid insurance pay? - Here are some basics about Insurance Coverage Criteria for approval for Breast Reduction. Breast Reduction varies from insurance company to insurance company. In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc. They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems.. Contact your individual company and request their specific Criteria and request preauthorization.Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to run , etc.Your plastic surgeon will then contact your insurance company for preauthorization.Here is some general information however to help you :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

Tom J. Pousti, MD · Answer

Sounds like you may be a great candidate for the breast reduction procedure.    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. Make sure you are  working with a well-trained/experienced board-certified plastic surgeon. Best wishes.

Has Medicaid ever paid full coverage for a breast reduction?

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Has Medicaid ever paid full coverage for a breast reduction?

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Everything you need to know about Breast Reduction

Our mission is to create a world where every investment in modern beauty is Worth It.