Does Medicare Cover Breast Reduction?

Medicare covers breast reduction surgery when it is medically necessary, such as for reducing pain or post-surgery reconstruction. Medicare does not cover breast reductions for cosmetic purposes.

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 B covers reduction mammaplasty procedures in outpatient surgical centers. If a beneficiary requires surgery as an inpatient and/or needs recovery time in a skilled nursing facility, Medicare Part A 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 Charges, 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 period 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 costs with a Medicare Advantage plan may be different than those with Original Medicare. Also, Medicare Advantage plan rules may require their members to use network providers for all services, supplies, and durable medical equipment.⁶Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021

Medigap

People with Original Medicare can purchase additional insurance, called Medigap, 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

• Deductibles
• Coinsurance
• Copayments
• 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 D 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

• 1
  Mayoclinic.org, “Breast reduction surgery“, Accessed October 29, 2021
• 2
  Medicare.gov, “Surgery“, Accessed October 29, 2021
• 3
  Medicare.gov, “Cosmetic surgery“, Accessed October 29, 2021
• 4
  pubmed.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
• 6
  Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
• 7
  Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
• 5
  Medicare.gov, “What Medicare Part D drug plans cover“, Accessed October 29, 2021
• 8
  Medicare.gov, “Breast prostheses“, Accessed October 29, 2021