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Does Medicare Cover Breast Reduction Surgery?

Breast reduction surgery is the seventh most popular procedure worldwide. In the U.S., the number of cosmetic breast reductions has skyrocketed, totaling over 71,000 surgeries in 2022. People choose breast reduction, also known as reduction mammoplasty, for various reasons. Some want to improve their appearance, while others have the procedure for medical issues like macromastia (excessively large breasts). Breast reduction surgery can also be done for gender affirmation or as part of breast cancer management. When breast reduction surgery is done for cosmetic purposes, Medicare won’t cover it. But Medicare will likely cover the procedure if it’s medically necessary.

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Does Medicare pay for breast reduction surgery?

It depends. If you're considering breast reduction surgery for cosmetic reasons, such as to change your appearance or improve your self-confidence, without a medical diagnosis or reason, Medicare won't cover the procedure.

However, Medicare will generally pay for breast reduction surgery when it's deemed medically necessary. In other words, the surgery needs to be related to a health issue.

How do I qualify for a breast reduction under Medicare?

You may qualify for a breast reduction under Medicare if you have certain health issues related to the size of your breasts. These include:

  • Persistent back or shoulder pain for at least six months that interferes with the activities of daily living (ADLs), such as bathing, dressing, or moving independently. You must also be experiencing this pain even after trying pain medications, supportive garments, a back brace, physical therapy, or weight loss.
  • Arthritic changes in your neck or upper spine that have lasted for at least six months and cause ongoing symptoms or activity limitations despite treatment. Symptoms may include nerve tingling in your arms, neck pain, muscle spasms, a curved spine, or postural changes.

You may also qualify if you have:

  • Skin irritation, infection, or intertriginous maceration (skin breakdown under your breasts) that doesn't go away with dermatology treatments.
  • Shoulder indentations with skin irritation even when wearing appropriate supporting bra.

Medicare may also consider the amount of breast tissue being removed when determining whether the surgery is cosmetic or medically necessary.

If you've had a mastectomy (breast removal) for medical reasons, Medicare will cover the reconstruction of both the affected and unaffected breasts.

How much does breast reduction surgery cost?

Breast reduction surgery costs can vary depending on several factors. The American Society of Plastic Surgeons reports that the average surgeon's fee for cosmetic breast reduction patients is $6,771. However, this is just a portion of the total cost.

To get a more accurate idea of how much your breast reduction surgery will cost, you'll need to consider additional expenses such as:

  • Fees for anesthesia
  • Charges for the operating room or hospital facility
  • Costs of medical tests
  • Special post-surgery garments, like a surgical bra
  • Prescriptions for necessary medications
  • Your surgeon's fee, which can vary based on their experience, surgical technique, and the location of their practice

Your total cost, including the factors above, can be as much as $19,000. To better understand your out-of-pocket expenses, ask your plastic surgeon's office directly. They can give you a more accurate estimate based on your medical needs and their fees.

How much does Medicare pay for breast reduction surgery?

Medicare can help cover the cost of a medically necessary breast reduction surgery through its different parts.

Medicare Part A

Medicare Part A primarily covers inpatient hospital stays. It also covers skilled nursing facility care, hospice care, and some home health services. Breast reduction surgeries are usually outpatient procedures. But if you need to be hospitalized after the procedure, Part A may help cover any inpatient-related costs.

You’ll generally need to pay your Part A deductible before Medicare starts covering your hospital stay. Once you pay the deductible, you won’t have any out-of-pocket expenses for your hospital room and care for the first 60 days you spend in the hospital.

Medicare Part B

Medicare Part B is medical insurance covering outpatient care, doctor’s visits, medical supplies, and some preventive services. Breast reduction surgery is generally performed as an outpatient procedure, so it would typically fall under Medicare Part B coverage.

Your healthcare provider may also need to submit a prior authorization request with documentation to Medicare for approval before the surgery. You may still be responsible for your Part B deductible and 20% coinsurance.

Under Original Medicare, the cost coverage for an outpatient breast reduction surgery can vary depending on the facility where the procedure is performed. For example, a hospital outpatient department may charge about $6,200 for facility fees, whereas an ambulatory surgical center may have much lower facility fees, around $2,500. Opting for an ambulatory surgical center may save you a considerable amount of money on the overall cost of your procedure, reducing the portion you'll need to pay out of pocket.

Hospital outpatient departments are areas where patients can receive outpatient services or procedures, such as surgeries or treatments that don't require an overnight stay. Ambulatory surgical centers are separate from hospitals and specialize in performing surgeries and procedures for patients who don't need more than 24 hours of care.

Part B also covers other related costs, such as outpatient medical supplies. For example, it may cover a surgical bra after your breast reduction surgery.

Medicare Part D

Medicare Part D helps cover the cost of prescription drugs. This means if you need pain medication, such as prescription-strength ibuprofen or acetaminophen, or an opioid medication like oxycodone during recovery from your breast reduction surgery, Medicare Part D can help pay for it.

Your surgeon may also prescribe antibiotics to take by mouth after the surgery. In this case, you can use Part D to help cover these prescription costs. Some people experience nausea after general anesthesia or while taking certain pain medications. If prescribed, anti-nausea medications would also fall under Part D coverage.

How much does breast reduction cost with Medicare?

If Medicare approves a breast reduction surgery, your out-of-pocket cost may fluctuate based on the type of facility where the procedure is performed. You'll generally be responsible for paying your deductible and coinsurance.

Based on the Medicare price calculator, you may pay about $720 out of pocket if you have breast reduction surgery at an ambulatory surgical center. This amount includes fees for both the facility and the doctor.

However, at a hospital outpatient department, you can expect to pay almost double, at about $1,450. This is because facility fees are much higher in a hospital setting than in an ambulatory surgical center.

Before you schedule your breast reduction surgery:

  • Ask your surgeon if the procedure is medically necessary and if Medicare will cover it
  • Find out where your surgeon operates — hospitals or surgical centers
  • Talk with your surgeon about the best facility for you based on your health
  • Make sure the recommended facility participates in Medicare
  • Compare your costs between a hospital and an ambulatory surgical center

You can visit Medicare.gov to learn more about the costs associated with your surgery at different facilities.

Medicare may cover breast reduction surgery if it is deemed medically necessary due to specific health issues, such as persistent pain or skin irritation. However, your surgeon will likely need to request prior authorization from Medicare before the surgery by providing documentation of the medical need. The cost of breast reduction surgery can vary depending on the surgeon's fee, facility charges, anesthesia, and medical supplies. Medicare Parts A, B, and D can help cover different aspects of the procedure, but you will still be responsible for paying deductibles and coinsurance.

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