Will Medicare Cover Breast Reduction for a 60 Year Old?

Hi. I am a 60 year old female with OA, PMR and GCA. I've also had stents placed in the coronary arteries and angioplasty. I am a size 38DDD, could probably go to and F.

I've had a yeast infection under both breast, a constant odor, severe neck and back pain and grooves in both shoulders. Will Medicare cover this procedure?

Doctor Answers 8

Breast reduction with medical problems

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With your medical problems, are you on or have you been on steroids or immunosuppressants recently? These medications can severely affect wound healing.

Breast reductions are a big operation with large wounds.This, in combination with your medical and cardiac history can make the procedure risky.

Your problem will be getting medical clearance for surgery, as well as finding a surgeon willing to do a risky procedure. Good luck.

Chapel Hill Plastic Surgeon

Medicare coverage for a breast reduction

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Unfortunately Medicare does not pre-approve anything.  If you meet the generally accepted criteria then most likely Medicare will pay but there is no guaranty.  You should have medical clearance from your cardiologist prior to even considering a breast reduction.   

Breast Reduction and Medicare?

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Thank you for the question. Given your description, it is very likely that Medicare will cover each breast reduction procedure. Consultation with a well experienced board-certified plastic surgeon will be helpful. Also, consultation with your cardiologist should also be  considered for a full workup prior to surgery. Best wishes.

Insurance and breast reduction

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Each insurance carrier has different criteria for pre-approval of a breast reduction. You should check with your insurance carrier. Check with medicaid

Insurance coverage for breast lift or breast reduction.

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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.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Medicare will cover Breast Reduction if you meet their criteria

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Yes, Medicare will cover breast reduction if you meet their criteria. A predetermination letter with photos can help you achieve the ok for the surgery. Your main issue is if you are medically cleared to under go this operation or any operation. Please ckeck with your primary and cardiac docs. 

Breast reduction under medicare

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I think Dr. Whitt has summarized the salient points excellently. It is likely that your procedure will be covered. The next decision is if your medical health is optimized. The third issue is a matter of risk assesment and you willingness to accept possible complications as a tradeoff for the potential benefits.

Medicare Coverage of Breast Reduction

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Medicare will cover reductions in some cases such as yours. The problem is that Medicare, unlike other insurance companies, will not give prior authorization. The other concern in your case is that your history of coronary disease certainly increases your risks of surgery. You should seek a consultation with a plastic surgeon. Following that, you will have to weigh the benefits/risks.

John Whitt, MD (retired)
Louisville 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.