Breast Augmentation and Tummy Tuck Ever Medically Necessary?

how would medicaid determine if a breast augmentation and tummy tuck is deemed medically neccesary?

Doctor Answers 25

Medicaid won't and shouldn't cover cosmetic surgery

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I would be very shocked to find any third party payor covering such surgery on the basis of medical necessity, let alone a government sponsored program like Medicaid.  Unfortunately those programs are designed to meet only the basic medical needs of the indigent who depend upon them, and it is unfair to expect the tax payers of our country to foot the bill for elective aesthetic surgery when so many other more serious medical needs go unmet due to limited resources.

San Diego Plastic Surgeon

Medically necessary?

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These are cosmetic procedures and not covered by insurance.  Such procedures can afford many benefits aesthetically and psychologically, but are not medically necessary. 

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

Cosmetic procedures are not covered by medicaid

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Both of these procedures are elective cosmetic procedures. Although there are many psychological benefits to such procedures, they are not medically necessary and therefore not covered by insurance including medicaid. 

Grant Stevens, MD
Los Angeles Plastic Surgeon
4.7 out of 5 stars 152 reviews

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Medical necessity

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I can not imagine that breast augmentation or a tummy tuck would ever be considered to be medically necessary

Norman Bakshandeh, MD, FACS
New York Plastic Surgeon

Insurance and BA

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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

Is breast augmentation or tummy tuck surgery ever covered by insurance?

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Typically breast augmentation and tummy tuck surgery are considered cosmetic procedures and not medically necessary. Occasionally patients who have lost a great deal of weight suffer from chronic irritation in the residual folds of the abdomen. If this chronic irritation cannot be managed with nonsurgical methods insurance companies will occasionally recognize a tummy tuck as being medically necessary. Occasionally when patients present with significant developmental abnormalities of the breasts insurance companies might regard the placement of breast implants as reconstructive in nature and provide coverage. In order to find out for sure your surgeon would need to communicate these findings to the insurance company and find out preoperatively if it will be covered.

John J. Edney, MD
Omaha Plastic Surgeon
4.8 out of 5 stars 133 reviews

Breast Augmentation & Tummy Tuck Are Not Generally Viewed as Medically Necessary by Insurance

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Breast augmentation and tummy tuck are not usually viewed as medically necessary by insurance carriers. These procedures are usually part of the Mommy Make-Over, and are viewed as cosmetic.
Occasionally, breast augmentation may be considered medically necessary when done to correct severe breast asymmetry. Occasionally, removal of excess abdominal skin following massive weight loss may be considered medically necessary. These examples are the exceptions and not the rule. Insurance coverage of these procedures would be extremely rare in most cases.

Breast Augmentation and Tummy Tuck not medically necessary

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Both breast augmentation and tummy tuck surgery are cosmetic in nature, therefore, most insurance companies or Medicaid would not cover these two procedures. The only time I have heard of this was years ago for spouses in the military.

Steven L. Ringler, MD, FACS
Grand Rapids Plastic Surgeon
5.0 out of 5 stars 72 reviews

Breast Augmentation and Tummy Tuck Ever Medically Necessar

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These procedures are purely cosmetic and are not covered by any insurance plans.  Sometimes breast reductions and breast reconstructions after cancer are covered by insurance companies. All cosmetic procedures are not considered medically necessary and are therefore not covered by insurance.

Paul Vitenas, Jr., MD
Houston Plastic Surgeon
4.8 out of 5 stars 116 reviews

Breast Augmentation and Tummy Tuck Surgery are Cosmetic; However, Breast Reconstruction or Reduction May be Covered

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Both breast augmentation and tummy tuck surgery are cosmetic in nature; therefore, insurance or Medicaid would not cover these two procedures.  Though some plans may cover conditions such as breast reduction and breast reconstruction surgery after breast cancer treatment in some cases.

C. Edwin Pittman, MD
Athens Plastic Surgeon

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.