Does Medicare cover breast reduction medical procedures?


Breast reduction operation, also identified as reduction mammaplasty, requires the elimination of pores and skin and tissue from the breasts, then reshaping them to a more compact size.

This variety of medical procedures has been on the increase since the pandemic. Cosmetic breast reduction surgeries—those that had been not regarded medically essential and compensated for out of pocket—increased by 54%, from 2019 to 2022, in accordance to the American Modern society of Plastic Surgeons (ASPS).

ASPS implies various factors may have contributed to this pattern, including an elevated health and health and fitness emphasis, distant operate and versatile schedules letting for much easier surgical procedures restoration, and additional time for reflection about personal comfort and ease and very well-getting.

Rewards of breast reduction surgical procedure may perhaps involve aid from upper again, neck, and shoulder pain, an amplified capability to training and take part in bodily things to do, and an improved self-graphic. 

More mature females and breast reduction surgical treatment

Dr. Lynn Damitz, main of the Division of Plastic and Reconstructive Medical procedures and Director of Aesthetic Surgery at the UNC School of Drugs in Chapel Hill, NC, and ASPS board vice president of well being policy and advocacy, has noticed an escalating range of ladies 65 and over pursuing breast reduction surgical procedures.

“I’ve surely found an increase in the very last two a long time,” she states. “My people about 65 are really motivated. Typically, they have been considering about carrying out the surgical procedures for a long time, and are completely ready to do a thing for by themselves.”

The expense of breast reduction medical procedures

The value of the surgical procedure can be substantial. In accordance to ASPS, the typical expense of a surgeon’s cost for cosmetic breast reduction is $6,771. Further service fees might incorporate anesthesia and clinic or surgical facility charges, health-related assessments, prescriptions, and article-surgical procedure garments.

“While many females pick out to pay out for the treatment out of pocket, commercial insurance plan, as nicely as Medicare and Medicare Gain, may perhaps address it,” says Damitz.

How to qualify for Medicare and Medicare Gain coverage of breast reduction surgical treatment

To get protection for breast reduction medical procedures by Medicare or Medicare Gain, it demands to be medically important, not beauty. Specially, the surgical procedures really should be necessary:

  • To lower reduce or eliminate symptoms caused by breast measurement
  • To cut down the size of a breast to make it symmetrical with a breast reconstructed after breast most cancers surgical procedure

Big breasts could trigger a range of not comfortable signs, including back again soreness, neck discomfort, heaviness, shoulder grooving, posture troubles, neuropathic soreness, numbness, irritation with pores and skin-on-skin get in touch with, rashes, skin conditions, and cleanliness difficulties.

“Before Medicare or Medicare Benefit protection is regarded as, people should have seasoned a amount of these signs or symptoms,” states Damitz. In addition, the Centers for Medicare & Medicaid Expert services (CMS) particulars these policies:

  • Surgeons must make absolutely sure that people have attempted non-surgical interventions to relieve breast agony or chafing, these types of as chiropractic treatment, bodily remedy, and dermatologic remedies
  • The symptom(s) ought to have been present for a minimum of six months
  • Interventions and health-related treatment method have been not capable to ease signs sufficiently
  • The affected individual has been notified of the risks of issues
  • The notes suggest the proposed sum of tissue to be eliminated and the rationale supporting that resolve

In addition, CMS guidelines condition that the quantity of breast tissue to be taken out will have to be proportional to the overall body area region, based on a measurement identified as the Schnur scale. Precisely, “If the individual’s physique floor space and fat of breast tissue eradicated fall higher than the 22nd percentile, then the surgical treatment is regarded medically sensible and essential with the acceptable criteria. If only a person breast meets the Schnur scale requirements breast tissue might be eradicated from the other breast to obtain symmetry.”

“This rule considers how disproportionate one’s breasts are in contrast to the relaxation of the entire body,” states Damitz. If you are obese, you might not fulfill the Schnur scale criteria, says Damitz.

Medicare and Medicare Edge protection of breast reduction surgical treatment

Only some surgeons acknowledge insurance plan coverage for breast reduction surgical procedures. Damitz is a single of them, and a important part of her breast reduction surgical procedures are protected by insurance coverage. Of the breast reductions she performs, 29% are covered by Medicare and Medicare Benefit, she suggests.

The acceptance system may perhaps be various for Medicare or Medicare Edge plan customers.

“Medicare does not supply prior acceptance of breast reduction surgery, but some Medicare Edge programs do,” says Damitz. “That signifies that even if you think you satisfy the qualifications for Medicare coverage, you may select to pay back upfront for the surgery, and hope for Medicare reimbursement afterward,” she states. It’s important to notice that if Medicare does not reimburse afterward, having said that, these service fees may well be considerably higher than a prenegotiated upfront fee, states Damitz.

If the patient’s Medicare Edge approach provides prior approval, it might shell out upfront for the operation service fees.

“Every Medicare Advantage prepare standards is various,” states Damitz. “It’s useful for clients to call their insurers in advance of time and inquire what the criteria are. That way, if they haven’t attempted all of the prerequisite non-surgical possibilities, they can think about accomplishing them 1st.”

As often with Medicare and Medicare Gain protection, deductibles and co-pays might use.

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