Does Medicare Cover Breast Reduction Surgery?

What are examples of medically necessary or cosmetic breast reduction?

There are several 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 have a bilateral mastectomy (or double mastectomy) of both breasts.
• Reducing pain caused by a large chest: A larger chest can cause pain in the neck, back, and rib cage. You can also experience misaligned 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. Breast reduction is considered medically necessary in both situations, 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% of the costs out of pocket.

If your self-esteem is affected by the size or shape of your breasts, talking with 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 affects your self-esteem.

How do you qualify for coverage?

In the case of breast reduction for reconstruction after a mastectomy, Medicare will cover the procedure.

Your doctor will 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 (Part C) plan, you might also need to ensure 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.

What are the out-of-pocket costs for covered 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 your plan if your reduction is medically necessary.

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

Part A

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

When you use Part A, you’ll be responsible for the Part A deductible. The 2024 deductible is $1,632.

You’ll need to pay this amount before your coverage kicks in. However, if you’ve already used other Part A services, such as hospital stays or home health care visits, you might have already paid your deductible.

Most people only spend a few days in the hospital, so you likely won’t have any copay costs for your stay.

However, you should know that starting on day 61, you’ll pay $408 a day in coinsurance. If you reach 91 days, you’ll pay $816 per day in coinsurance for up to 60 lifetime reserve days.

Part B

If you have an outpatient breast reduction, it will be covered under Part B. Outpatient procedures can be performed at hospitals or stand-alone surgical centers.

The Part B deductible is $240 in 2024. You’re also responsible for 20% of the cost 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 2024, the premium is $174.70 for most people.

Part C

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

The bottom line

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. Your costs will depend on where you have the surgery and on your plan.