Medicare covers breast reduction surgery when it is medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice., such as for reducing pain or post-surgery reconstruction. Medicare does not cover breast reductions for cosmetic purposes.
Key Takeaways
- Breast reduction is the removal of excess fat, tissue, and skin from heavy breasts to reduce discomfort or for cosmetic reasons.
- A board-certified plastic surgeon should be consulted to know what to expect from a breast reduction.
- Medicare will cover breast reductions to relieve pain or for reconstructive surgery after a mastectomy (breast removal).
- Medicare will not cover breast reductions for cosmetic procedures.
- Medicare can provide coverage for breast prostheses after a breast reduction or mastectomy if needed.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). may cover breast reductions, but the beneficiary will have to use providers within the plan.
What Is Breast Reduction Surgery?
A reduction mammaplasty, also known as breast reduction surgery, is the reconstruction of a person’s breasts by removing breast tissue, fat, and excess skin. Breast reduction can be used to ease a person’s negative self-image, enhance physical activity, and relieve pain from a proportionally large breast size, such as:1Mayoclinic.org, “Breast reduction surgery“, Accessed October 29, 2021
- Back pain
- Neck pain
- Shoulder pain
A board-certified plastic surgeon should be consulted when considering a breast reduction. The surgeon can provide an idea of the results and risks a person can expect from the surgery. The surgeon may even advise against the procedure if pain due to heavy breasts can be resolved with weight loss.1Mayoclinic.org, “Breast reduction surgery“, Accessed October 29, 2021
How Does Medicare Cover Breast Reduction Surgery?
Medicare covers breast reduction surgery procedures when it is medically necessary to reduce pain or for breast reconstruction after a mastectomy2Medicare.gov, “Surgery“, Accessed October 29, 2021. Breast reductions for cosmetic purposes are not covered by Medicare3Medicare.gov, “Cosmetic surgery“, Accessed October 29, 2021. Beneficiaries may not qualify for a breast reduction if their body mass index (BMI) is 30 or higher unless they have shown that diet and exercises did not resolve their condition.
How Much Does Breast Reduction Surgery Cost?
The cost for a breast reduction will vary from area to area. According to the National Library of Medicine, the average cost of an outpatient breast reduction is $9,077, while an inpatient breast reduction has an average cost of $19,975.4pubmed.ncbi.nlm.nih.gov, “Outpatient Reduction Mammaplasty Offers Significantly Lower Costs with Comparable Outcomes: A Propensity Score-Matched Analysis of 18,780 Cases“, Accessed November 11, 2021
Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. covers reduction mammaplasty procedures in outpatient surgical centers. If a beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. requires surgery as an inpatient and/or needs recovery time in a skilled nursing facility, Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. provides coverage.2Medicare.gov, “Surgery“, Accessed October 29, 2021
Increasingly, breast reduction surgery is an outpatient procedure. Medicare pays 80 percent of all approved costs once the beneficiary has paid their annual Part B deductible. If the surgeon, anesthesiologist, or the surgical center charge Part B Excess ChargesA Medicare Part B excess charge is the difference between a health care provider’s actual charge and Medicare’s approved amount for payment., the beneficiary is responsible for paying these costs.
When a breast reduction procedure is performed as an inpatient procedure the hospital costs are covered by Medicare Part A, which has a benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit... deductible. However, physician services for non-hospital employees, which generally includes the surgeon and the anesthesiologist, are covered under Part B. Hospital services related to inpatient surgery include things like daily room and board, laboratory services, diagnostic tests, surgical equipment and supplies, anesthesia, and the services of nurses, and other health professionals.
Medicare Advantage
Medicare Advantage plans are required to cover the same services as Medicare Part A and Part B, in addition to any expanded services offered. That includes breast reduction surgery. However, a beneficiary’s out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. with a Medicare Advantage plan may be different than those with Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. Also, Medicare Advantage plan rules may require their members to use network providers for all services, supplies, and durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds..6Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
Medigap
People with Original Medicare can purchase additional insurance, called MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage., to help cover their Medicare out-of-pocket costs. Medicare supplement insurance, as it is also known, is available through private insurance companies. A Medigap policy will cover some or all of the out-of-pocket costs associated with Medicare-approved breast reduction surgery services. These costs include:7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
- Blood
Post-Surgery Medication Costs
When post-surgery medication is required it will generally be covered by a beneficiary’s Medicare Part D plan. Depending on the Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plan, members may pay an annual deductible, before the plan begins paying its share, as well as a copayment.5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed October 29, 2021
Breast Prostheses
If external breast prostheses or a post-surgical bra is required after a breast reduction or mastectomy, Medicare Part B covers these items when ordered by the patient’s doctor. Medicare Part A covers surgically implanted breast prostheses implanted in an inpatient setting. Part B covers surgically implanted breast prostheses delivered in an outpatient setting.8Medicare.gov, “Breast prostheses“, Accessed October 29, 2021
Summary
If you are discussing a breast reduction procedure with your doctor, and you’re wondering if it’s Medicare-approved, now you know. Medicare covers this surgery, when ordered by your doctor, for the relief of chronic back pain related to your breasts. It is also covered when you need reconstructive surgery following a mastectomy. In both cases, Original Medicare or a Medicare Advantage plan pays their share. Your out-of-pocket costs will vary depending on the type of coverage you have.
Citations
- 1Mayoclinic.org, “Breast reduction surgery“, Accessed October 29, 2021
- 2Medicare.gov, “Surgery“, Accessed October 29, 2021
- 3Medicare.gov, “Cosmetic surgery“, Accessed October 29, 2021
- 4pubmed.ncbi.nlm.nih.gov, “Outpatient Reduction Mammaplasty Offers Significantly Lower Costs with Comparable Outcomes: A Propensity Score-Matched Analysis of 18,780 Cases“, Accessed November 11, 2021
- 6Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
- 7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
- 5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed October 29, 2021
- 8Medicare.gov, “Breast prostheses“, Accessed October 29, 2021