Here’s When Medicare Will Cover Breast Reduction Surgery | Old North State Wealth News
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Here’s when Medicare will cover breast reduction surgery

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Breast reduction surgery, also known as reduction mammaplasty, involves the removal of skin and tissue from the breasts, then reshaping them to a smaller size.

This type of surgery has been on the rise since the pandemic. Cosmetic breast reduction surgeries—those that were not considered medically necessary and paid for out of pocket—increased by 54%, from 2019 to 2022, according to the American Society of Plastic Surgeons (ASPS).

ASPS suggests several factors may have contributed to this trend, including an increased health and fitness focus, remote work and flexible schedules allowing for easier surgery recovery, and more time for reflection about personal comfort and well-being.

Benefits of breast reduction surgery may include relief from upper back, neck, and shoulder pain, an increased ability to exercise and participate in physical activities, and an improved self-image. 

Older women and breast reduction surgery

Dr. Lynn Damitz, chief of the Division of Plastic and Reconstructive Surgery and Director of Aesthetic Surgery at the UNC School of Medicine in Chapel Hill, NC, and ASPS board vice president of health policy and advocacy, has seen an increasing number of women 65 and over pursuing breast reduction surgery.

“I’ve definitely seen an increase in the last two decades,” she says. “My patients over 65 are highly motivated. Often, they have been thinking about doing the surgery for a long time, and are ready to do something for themselves.”

The cost of breast reduction surgery

The cost of the surgery can be significant. According to ASPS, the average cost of a surgeon’s fee for cosmetic breast reduction is $6,771. Additional fees may include anesthesia and hospital or surgical facility costs, medical tests, prescriptions, and post-surgery garments.

“While many women choose to pay for the procedure out of pocket, commercial insurance, as well as Medicare and Medicare Advantage, may cover it,” says Damitz.

How to qualify for Medicare and Medicare Advantage coverage of breast reduction surgery

To get coverage for breast reduction surgery by Medicare or Medicare Advantage, it needs to be medically necessary, not cosmetic. Specifically, the surgery should be necessary:

  • To reduce decrease or eliminate symptoms caused by breast size
  • To reduce the size of a breast to make it symmetrical with a breast reconstructed after breast cancer surgery

Large breasts may cause a number of uncomfortable symptoms, including back pain, neck pain, heaviness, shoulder grooving, posture problems, neuropathic pain, numbness, discomfort with skin-on-skin contact, rashes, skin conditions, and hygiene issues.

“Before Medicare or Medicare Advantage coverage is considered, patients must have experienced a number of these symptoms,” says Damitz. In addition, the Centers for Medicare & Medicaid Services (CMS) details these rules:

  • Surgeons must make sure that patients have tried non-surgical interventions to alleviate breast pain or chafing, such as chiropractic care, physical therapy, and dermatologic treatments
  • The symptom(s) must have been present for a minimum of six months
  • Interventions and medical treatment were not able to alleviate symptoms adequately
  • The patient has been notified of the risks of complications
  • The notes indicate the proposed amount of tissue to be removed and the rationale supporting that determination

In addition, CMS rules state that the amount of breast tissue to be removed must be proportional to the body surface area, based on a measurement called the Schnur scale. Specifically, “If the individual’s body surface area and weight of breast tissue removed fall above the 22nd percentile, then the surgery is considered medically reasonable and necessary with the appropriate criteria. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast to achieve symmetry.”

“This rule considers how disproportionate one’s breasts are compared to the rest of the body,” says Damitz. If you are overweight, you may not meet the Schnur scale criteria, says Damitz.

Medicare and Medicare Advantage coverage of breast reduction surgery

Only some surgeons accept insurance coverage for breast reduction surgery. Damitz is one of them, and a significant portion of her breast reduction surgeries are covered by insurance. Of the breast reductions she performs, 29% are covered by Medicare and Medicare Advantage, she says.

The approval process may be different for Medicare or Medicare Advantage plan members.

“Medicare doesn’t offer prior approval of breast reduction surgery, but some Medicare Advantage plans do,” says Damitz. “That means that even if you think you meet the qualifications for Medicare coverage, you may choose to pay upfront for the surgery, and hope for Medicare reimbursement afterward,” she says. It’s important to note that if Medicare does not reimburse afterward, however, these fees may be substantially higher than a prenegotiated upfront fee, says Damitz.

If the patient’s Medicare Advantage plan offers prior approval, it may pay upfront for the surgery fees.

“Every Medicare Advantage plan criteria is different,” says Damitz. “It’s helpful for patients to contact their insurers ahead of time and ask what the criteria are. That way, if they haven’t tried all of the prerequisite non-surgical options, they can consider doing them first.”

As always with Medicare and Medicare Advantage coverage, deductibles and co-pays may apply.

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