Does Medicaid Cover Breast Reduction?

Finding a surgeon who accepts a particular insurance can be accomplished by contacting the coverage provider.
The requirements are similar across the board regardless of which provider:
-Patients will need to demonstrate/document symptomatic macromastia: back/neck/shoulder pain; rashes in the folds beneath the breasts; bra strap grooving.
-Patients will also need to demonstrate failure of more conservative measures (weight loss, physical therapy, medical therapy)
-The weight resected will be determined by the Schnurr scale which is a function of BSA.With regards to your specific question, Medicaid will cover a medically necessary reduction for macromastia. The challenge will not be coverage but rather finding a provider who accepts Medicaid.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Thank you for your question
You will need to call Medicaid to find out if breast reduction surgery is a covered benefit and what plastic surgeons participate with it. Best wishes!

Thank you for the question.

Medicaid has been known to cover breast reduction surgery. For multiple reasons,  most plastic surgeons that I know of to not work with Medicaid. I think finding a reputable plastic surgeon who will work with Medicaid will be the challenge you will face.

Best wishes.

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

Medicaid, the Federally financed insurance net for the Nation's poor and its partially State funded versions (Cal-Aid, Tenn Care etc) were designed as a safety net to pay only for serious medical conditions. It was never meant to compete with or act as comprehensive health care plans (those referred to Res Obama and leading Democrats as "Cadillac" plans). 

As a rule, all Medicaid plans compensate surgeons extremely poorly and are commonly associated with prolonged bureaucratic hassles that intimidate and repel most well meaning surgeons.

With huge variations in Medicaid and State "coverage", you would be advised to check your own plan to see if your case would be covered AND if it is, which Plastic surgeons in your area would work with your Medicaid plan.

Yes it does but the issues are finding a boarded PS who accepts Medicid. Also a hospital that also participates with Medicaid. Both are difficult to find. Best of Luck

From MIAMI Dr. B

Medicaid may cover a breast reduction if certain critera are met--symptoms, failure of conservative therapy, meeting appropriate threshold of tissue removed.  The problem is that Medicaid reimbursement is usually rediculously low and you may therefore have trouble finding a plastic surgeon who will accept Medicaid.

Insurance Coverage for Breast Reduction





Answer by George J. Beraka, MD

Manhattan Plastic Surgeon



80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.