Does Having Medicare and Medigap Increase My Chances For Coverage of Breast Reduction?

I hear a lot about what is required for insurance coverage of breast reduction surgery. I also hear about how difficult it can be to find a surgeon who takes Medicare. I have both Medicare and a Medigap policy. Will this make it easier to get coverage?

Doctor Answers 6

Medicare Covering Breast Reduction Surgery

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Thank you for your question.

Each insurance company is different with what they require to "authorize" the breast reduction surgery through insurance.  I write a letter and send photos of the patient when trying to get authorization (I am sure most plastic surgeons do this as well).  Also getting supporting letters from other doctors who can document that you have had neck, back and shoulder pain and/or rashes due to the large breasts. Supporting documentation is usually very helpful.

Because Medicare does not give "pre-approval" so many surgeons are hesitant to do surgery and not know that they will be paid for their time.

Coverage for Breast Reduction is based on body surface area

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Insurance authorization requires medical problems such as pain, rash or bleeding.  The amount removed is based on body surface area which is determined by your height and weight.  I have done Medicare patients with the understanding that I meet the same criteria of other insurance companies.  I have never been denied, however Medicare ONLY pays about $1000 and the normal fee of a breast reduction is over $6000 in Houston, Texas.

Best of Luck,

Gary Horndeski, M.D.

Medicare payment for Breast Reduction

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

To reduce the use of its services and make things very ard for Plastic surgeons none of the Federal health care entities would tell the surgeons or patients BEFORE surgery if the operation will be or not be paid for.  Without knowing if the operation would be paid for and knowing the payments are woefully low most surgeons prefer not to engage in a situation involving uncertainty and unhappy patiens. 

Your having Medigap means that If Medicare  pays for the surgery it will pay 80% of ts usual rate but instead of you having the pay the other 20%, it will be paid by the Medigap policy. 

Peter A. Aldea, MD
Memphis Plastic Surgeon

Medicare coverage for breast reduction

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

At the time of your consultation the details of insurance and medicare coverage will be discussed. This will definitely vary from state to state.   The only way to know for sure is to begin the process.  The biggest problem is that medicare does not pre-approve anything so documentation is critical.  

Medicare Will Not Provide Preauthorization

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Medicare and other federal health insurance programs (such as Federal Blue Cross/Blue Shield) will not tell beneficiaries prior to surgery if they will or will not cover any procedure.  There are some written guidelines available but they they vary from state to state.  It is, therefore, somewhat of a crapshoot, unless quite clearcut, whether a procedure (including reduction) will or will not be covered.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Medicare coverage for breast reduction

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
Medicare does cover breast reduction; if Medicare covers it, then the remaining 20% would be covered by your Medigap policy, subject to your deductible and co-payment. Each Medicare intermediary in the country has different rules. In NY, Medicare does not preauthorize any surgery so it is up to the plastic surgeon to determine whether the case is likely to be covered. Then, it is common for Medicare to request supporting documentation after the fact in order to make its decision. Patients, therefore, have to sign waiver forms agreeing to pay in the event that Medicare declines to cover the procedure.

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.