How to Get Your Breast Reduction Surgery Covered by Medicare

Breast reduction surgery, also known as reduction mammoplasty, involves the removal of excess fat and tissue from the breasts to diminish their size and weight.
Breast reduction surgery, also known as reduction mammoplasty, involves the removal of excess fat and tissue from the breasts to diminish their size and weight. Photo courtesy | Facebook

 

Discover if breast reduction surgery is covered by Medicare, including details on the cost, medical eligibility criteria, and information on dual eligibility.

While breasts come in various shapes and sizes, breast reduction surgery can be advantageous if having large breasts hinders routine activities or causes considerable discomfort.

However, the question remains: does insurance, such as Medicare, cover the costs of breast reduction surgery?

Before concluding the article, I will attempt to address whether Medicare includes coverage for breast reduction procedures.

What is breast reduction surgery?

Breast reduction surgery, also known as reduction mammoplasty, involves the removal of excess fat and tissue from the breasts to diminish their size and weight.

This procedure aims to alleviate issues such as back pain, chafing or rash beneath the breasts, and neck strain.

Additionally, breast reduction surgery may address psychological symptoms linked to having large breasts.

While many women opt for this surgery to alleviate health-related concerns, it is worth noting that breast reduction is occasionally performed for cosmetic reasons.

Breast reduction surgery
Breast reduction surgery: Image of a Doctor explaining to the patient how the procedure is done (photo courtesy | Facebook)

 

What is Medicare Insurance?

Medicare, a federal health insurance program, caters to individuals aged 65 and older, certain younger individuals with disabilities, and those with end-stage renal disease or ALS.

Comprising Part A, Part B, Part C, and Part D, each segment offers distinct coverage and costs.

  • Part A includes inpatient hospital care, skilled nursing facility care, hospice care, and certain home health care. Although most individuals do not pay a monthly premium for Part A, there are deductibles and coinsurance for specific services.
  • Part B covers doctors’ services, outpatient care, medical supplies, and preventive services. A monthly premium is applicable for Part B, with variations based on income. Deductibles and coinsurance are also present for some services.
  • Part C, or Medicare Advantage, provides an alternative for Medicare coverage through private insurance companies, encompassing benefits from Part A and Part B. Part C plans may offer additional benefits like vision, hearing, dental, and prescription drug coverage, each with distinct costs and rules.
  • Part D addresses prescription drugs offered by private insurance companies to reduce medication costs. Plans differ in premiums, deductibles, copayments, and formularies.

Financed by taxes, premiums, and other revenue sources, Medicare facilitates access to healthcare but does not cover everything.

Certain services, such as long-term care, dental care, eye exams, and hearing aids, are not covered.

To offset costs, individuals may opt for supplemental insurance like Medigap or Medicare Advantage plans.

medicare
medicare | photo courtesy | Health Guide

 

Is breast-reduction surgery covered by Medicare?

Is it yes or no? Securing coverage for reduction mammoplasty through insurance providers like Medicare is improbable, primarily because the procedure is often considered aesthetic.

Nevertheless, there are specific situations in which they might offer coverage.

The eligibility requirements for Medicare regarding breast reduction surgery coverage are intricate, making it challenging to ascertain individual qualifications without seeking guidance from a surgeon.

How can one secure insurance coverage for breast reduction?

Medicare may cover the surgery if deemed medically necessary but only considers beneficiaries with symptoms from their breast size persisting for at least six months.

  1. Discomfort in the back or shoulders affecting daily activities, being unresponsive to weight loss, or wearing supportive garments.
  2. Arthritic or progressive spinal issues persist despite conservative management, leading to ongoing symptoms or lifestyle restrictions.
  3. Unresolved intertrigo (infection under the breasts) despite dermatologic treatment.
  4. Skin irritation or damage from wearing breast-supporting garments.

Determining the exact extent of Medicare coverage for breast tissue removal is challenging, as it hinges on each individual’s unique anatomy.

Some women seek reduction mammoplasty on a healthy breast for symmetry after reconstructive cancer treatment. In such cases, Medicare views it as non-cosmetic and may offer coverage.

If eligible for Medicare coverage, you’ll incur a deductible under Medicare Part A, set at $1,632 in 2024 per benefit period. This period spans from hospital admission until 60 days post-inpatient care.

No coinsurance costs apply for the first 60 days. From days 61 to 90, you bear $408 in daily coinsurance, increasing to $816 for each lifetime reserve day from day 91 onwards.

Once lifetime reserve days are exhausted, beneficiaries cover all costs. Depending on coverage levels, Medicaid may assist with deductibles and coinsurance for those enrolled in both programs.

What is the cost of breast-reduction surgery without Medicare?

Reduction mammoplasty costs vary based on location, surgeon, and whether it’s cosmetic or health-related.

The American Society of Plastic Surgeons reports an average cost of $5,913 for cosmetic breast reduction procedures.

It’s important to note that this amount excludes additional expenses for anesthesia, supplies, or the utilization of the hospital’s facilities.

Consequently, the actual cost of breast reduction surgery is likely to be considerably higher.

Medicare Supplement (Medigap) Plans Can Help Pay for Covered Breast Reduction Surgery

Medicare Supplement (Medigap) Plans offer assistance with covered breast reduction surgery costs.

Marketed by private insurance firms, these plans provide coverage for:

  1. Medicare deductibles
  2. Coinsurance
  3. Copayments.

With various types available, you can find a plan that aligns with your coverage needs and budget.

If Medicare covers your surgery, a Medigap plan can help with Part A deductibles, copays, or coinsurance, depending on the plan type.

Frequently Asked Questions about Reduction Surgery Covered by Medicare

Is breast-reduction surgery covered by Medicare?

Individuals often inquire about Medicare coverage for breast reduction surgery, seeking clarity on whether the procedure is deemed medically necessary.

What Criteria Must Be Met for Medicare to Cover Reduction Mammoplasty?

This question delves into the specific conditions or symptoms that must be present to qualify for Medicare coverage, addressing the clinical necessity of the surgery.

Does Medicare consider cosmetic reduction mammoplasty?

Many individuals wonder if Medicare extends coverage for cosmetic reduction mammoplasty, prompting a need to distinguish between medically necessary procedures and those pursued for aesthetic reasons.

How much breast tissue removal will Medicare cover?

Given the unique anatomy of each person, there is often uncertainty about the extent of coverage provided by Medicare for the removal of breast tissue during reduction mammoplasty.

Are there additional costs with Medicare coverage for breast reduction mammoplasty?

Prospective patients inquire about potential out-of-pocket expenses, such as deductibles, coinsurance, or other costs associated with Medicare coverage for reduction mammoplasty.

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