Will Medicare pay for fat transfer for breast reconstruction with implants? Ts?

Question

The fat would be harvested from thighs since I have very little on the abdomen. Does the harvesting donor site matter for insurance purposes? Do other insurance carriers pay for this procedure? Can the fat transfer be done in a revision procedure and will it be covered by Medicare?

Nathan Kludt, MD · Answer

Thank you for your question. In my experience, insurance will usually pay for fat grafting done both at the time of reconstruction or also later if needed for revision for a reconstructed breast. The donor site of the fat has no relevance regarding insurance coverage. Best of luck, Dr. Kludt

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

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

Nelson Castillo, MD · Answer

Thank you for your question.  In cases of breast reconstruction insurance will typically pay for the initial surgery as well as any future procedures needed.  Always best to speak to your insurance carrier as well as your surgeon to ensure that there are no surprises during the billing process.  The site of harvest for your fat grafts does not matter for insurance.  Hope that this helps.

Joseph Poggi, MD · Answer

Most insurance carriers offer the ability for the doctors office to preauthorize a procedure so that you know you are getting a covered benefit.  Medicare does not provide for this process.  Generally speaking, procedures to reconstruct a breast from "acquired breast absence" as well as procedures on the opposite breast to achieve symmetry and revision procedures needed are a covered benefit.  One caveat is that some insurance carriers have recently been denying procedures after the initial reconstruction is performed.  Unfortunately, it gets complicated and is ever changing, especially since all the insurance rules and coverages are in a state of flux!  Good luck and look for a surgeon that is a good patient advocate!

Will Medicare pay for fat transfer for breast reconstruction with implants? Ts?

Answers (4)

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