Does Medicare Cover Breast Reduction Surgery?

Whether or not Medicare will cover breast reduction depends on your reason for having the surgery. There are several common reasons you might want or need a breast reduction, including:

• Reconstruction after a mastectomy for breast cancer. After a mastectomy, you may want to have surgery to reconstruct your breasts or to improve their symmetry. For example, if you had a single mastectomy of one breast, you may want surgery to make your breasts match again. Reconstruction can also be done if you had a bilateral mastectomy (or double mastectomy) of both breasts.
• Reducing pain caused by having a large chest. Having a larger chest can cause pain in the neck, back, and rib cage. You can also experience poor posture, which can lead to more pain. Your doctor might recommend breast reduction surgery to relieve this type of pain.
• Improving your overall appearance and self-esteem. You might choose to have breast reduction surgery because you’re unhappy with the size of your breasts. Breast reduction can sometimes help you have a more youthful appearance or balanced figure.

Medicare only pays for breast reduction for the first two reasons. In both of these situations, the breast reduction is considered medically necessary, so Medicare will cover it.

If you’re in the third situation, Medicare would consider your surgery cosmetic and would not cover it. You’d need to pay for 100 percent of the costs out of pocket.

If your self-esteem is being seriously affected by the size or shape of your breasts, talking to a licensed therapist might be helpful. Medicare does cover mental health services under Part B (medical insurance).

You can get counseling appointments covered and work with a professional on the best way to address how your body is affecting your self-esteem.

You’ll qualify to have your breast reduction covered if you meet Medicare’s conditions.

In the case of breast reduction for reconstruction after a mastectomy, Medicare will cover the procedure. Your doctor will just need to provide documentation to Medicare that you’re having breast reduction because of your mastectomy.

If you’re having breast reduction for pain, you’ll need to make sure you meet a few more conditions. Your doctor will need to verify that:

• the surgery is necessary to treat your pain
• nonsurgical procedures haven’t worked for you
• your symptoms have lasted at least 6 months

In some cases, your pain might be caused by a specific condition of the breasts called breast hypertrophy (or gigantomastia). Hypertrophy causes the breasts to increase in weight and density, causing pain and other problems.

Medicare will pay for breast reduction in the case of hypertrophy, as long as your doctor states that it is the primary cause of your pain or other symptoms.

You’ll need to get your breast reduction performed at a facility that accepts Medicare to receive full benefits. You can ask your surgeons if they accept Medicare before your first visit. You can also search for providers using the Medicare website.

If you have a Medicare Advantage (Medicare Part C) plan, you might also need to make sure the surgeon and facility you want to use is in network. You can search for surgeons within your plan’s network, contact your plan directly, or ask your surgeon’s office if they accept your plan.

Medicare does not cover any cosmetic surgery procedures. This means that if your procedure is elective and for appearance only, you’ll pay 100 percent of the costs.

This is true no matter what kind of Medicare plan you have. Neither Advantage plans nor Medigap plans offer additional coverage for cosmetic procedures.

The costs you’ll pay for your breast reduction depend on the type of Medicare plan you have and the facility where you have your surgery. You’ll be covered no matter which plan you have, as long as your reduction is medically necessary.

Medicare Advantage plans are required to cover everything that Medicare parts A and B (original Medicare) cover. However, the cost you’ll pay might be different from plan to plan.

Medicare Part A

If you have original Medicare and are admitted as an inpatient for your breast reduction, it will be covered under Medicare Part A.

There are many reasons you may need to be admitted for this procedure, including concerns of possible complications. This may also be the case if you’re having breast reduction at the same time or just after a mastectomy.

When you use Part A, you’ll be responsible for the Part A deductible. The Part A deductible in 2020 is $1,408. You’ll need to pay this amount before your coverage kicks in. You might have already paid into your deductible if you’ve already used other Part A services, such as other hospital stays or home health care visits.

You won’t have any copay costs for days spent in the hospital until you reach your 60th day. Most people don’t need more than a few days in the hospital for a breast reduction. However, you should know that starting on day 61, you’ll pay $352 a day in coinsurance. If you reach 91 days, you’ll pay $704 per day in coinsurance for a total of 60 lifetime reserve days.

Medicare Part B

Your breast reduction will be covered under Medicare Part B if you have an outpatient procedure and are using original Medicare. Outpatient procedures can be done at hospitals or stand-alone surgical centers.

The Part B deductible is $198 in 2020. However, you’re also responsible for 20 percent of the cost of Medicare-approved procedures once you meet your deductible.

So, for example, if the Medicare-approved amount for your breast reconstruction was $6,000, Medicare would pay $4,800 and you’d pay $1,200.

Part B also has a monthly premium. In 2020, the premium is $144.60 for most people.

Medicare Part C

Medicare Part C is also known as Medicare Advantage. Medicare Advantage plans are offered by private companies that contract with Medicare. They offer the same coverage as original Medicare and often include extras such as vision or dental coverage.

Your breast reduction costs under Medicare Advantage will depend on your plan. You’ll generally have copays for procedures or hospital stays. You can call your plan ahead of the procedure to ask about costs, if you’re unsure how much they’ll cover.

Remember that no plan pays for elective cosmetic procedures. You’ll need to pay the full cost in that case. The cost can vary depending on the surgeon you choose, but a 2019 survey found that the average cost for breast reduction surgery in the United States was $5,475.

Your doctor will advise you how to prepare for breast reduction in a way that addresses your specific needs. However, there are some general things you can expect.

Before surgery

Your preparation for surgery will likely include a few different exams. Your doctor will need to perform a routine breast exam, and you might also need a mammogram and other lab work.

These tests will help your doctor figure out if you’re a good candidate for breast reduction and if you’re healthy enough for surgery.

Your doctor will also ask you questions about your medical history and your family’s medical history. It’s important to answer these questions honestly.

Once your doctor has cleared you for the procedure, you’ll need to take a few other steps to prepare. These might include:

• stop taking some over-the-counter pain medications a few days before surgery
• quit smoking if you’re smoker
• arrange a ride home and any care you might need after the procedure
• restrict or stop food and water on the day of surgery

Be sure to follow any specific instructions your doctor gives you to prepare.

During surgery

During the procedure, the skin, tissue, and fat of your breasts will be reconstructed to get the desired outcome. Your procedure might be inpatient or outpatient. Most people go under general anesthesia for breast reduction.

During recovery

Your breasts will be wrapped in bandages after surgery. You might also have drainage tubes attached to your breasts. These tubes help drain fluids and reduce any swelling.

You’ll typically keep your bandages and tubes on for several days. Once the bandages are removed, you’ll likely need to wear special post-surgical bras for a few weeks.

You can expect to take at least a week or two off work after your surgery to rest and recover. Most experience pain and tiredness after surgery, making it hard to do everyday activities.

You’ll be prescribed a medication to help manage pain. Your doctor can advise you on when you can get back to activities like lifting and exercise.

Your breasts might be swollen after your procedure. It might seem like they’re not smaller because of this, but you’ll notice the change once the swelling goes down and your body heals. Your doctor will set follow-up appointments to check on your progress.

It’s important to keep an eye on your stitches. If you notice any coming undone or any pus coming from the area, call your doctor immediately.

What are the long-term outcomes?

You’ll generally find that you feel better once the healing process is complete. If you were having neck or back pain before, you can expect some or all of that pain to be gone.

You might also need time to adjust to your new appearance and even feel depressed or anxious after your surgery. This is a common experience, but if these feelings persist, talk to your doctor about seeing a counselor for help.

You also might need to buy smaller clothes to fit your new body, especially if your breast size has changed drastically.

You’ll also likely have scars after your surgery. Your scars will fade over time, and you can improve healing by avoiding activities like lifting after surgery.

In some cases, you might need to have another surgery later on. This surgery can correct any complications or to revise the original surgery to improve your final outcome.

If you need a breast reduction, Medicare may cover your costs. Keep in mind that:

• Medicare doesn’t cover cosmetic procedures.
• Medicare will cover breast reduction when it’s medically necessary.
• Medically necessary situations include reconstruction after a mastectomy or reduction to help with pain.
• You can get coverage through original Medicare or a Medicare Advantage plan.
• Your costs will depend on where you have the surgery and on your plan.