What are the odds of Medicaid approving my breast reduction?

Question

I am a 24 year old female. I have ha back pain since I was about 15 years old. I am bursting out of a DD bra at the moment and would like a reduction to a small C.

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

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 functional problems like back pain help: 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

Jennifer Greer, MD · Answer

Getting pre approval for surgery from Medicaid and Medicare is often an area of confusion. MediCARE, which provides healthcare for those over age 65, does not provide pre approval for surgery. MediCAID, which provides health care for those with low incomes, will provide a pre approval or predetermination. The approval process depends on :A documented history of symptoms which are not improved by non-surgical treatments, such as physical therapy, pain medications, or weight loss (if indicated)Large breast sizeThe first step is for you to see your primary care doctor regarding your back pain. He or she will rule out any causes other than large breasts, and recommend any medical (i.e. nonsurgical) treatments that may help.After you have tried these nonsurgical treatments, then your primary care doctor can give you a referral to a plastic surgeon that treats patients with Medicaid. Best of luck to you!

Vincent N. Zubowicz, MD · Answer

Medicaid doesn't prior approved surgery so you'll not known in advance if it's covered. You'll need to find a surgeon who works with Medicaid.

Tom J. Pousti, MD · Answer

I am sorry to hear about the problems you are experiencing secondary to disproportionately large breasts. Although you may be an excellent candidate for breast reduction surgery I think the biggest challenge  you may face is finding a reputable plastic surgeon who works with Medicaid.  You will need to make contact with board-certified plastic surgeons in your area to see if they work with the Medicaid organization.Best wishes.

Kenneth D. Christman, MD · Answer

You can ask and see what Medicaid will do in your state.  Generally 500 gms of breast tissue must be removed from each breast for insurance coverage.

What are the odds of Medicaid approving my breast reduction?

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What are the odds of Medicaid approving my breast reduction?

Answers (6)

Answer: What are the odds of Medicaid approving my breast reduction?

Answer: What are the odds of Medicaid approving my breast reduction?

Answer: Medicaid covering breast reduction

Answer: Medicaid covering 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.