Does Medicare Cover Breast Reduction

Medical insurance providers don’t provide coverage for various medical procedures, cosmetic surgery is one of them.

A woman who wants to go for a breast reduction procedure has one question in common: Does Medicare cover breast reduction?

Let’s find out the answer.

What is Breast Reduction

Cosmetic surgery is a specialized branch of plastic surgery focused on enhancing appearance through surgical and medical techniques. Cosmetic surgery is a part of plastic surgery performed by skilled plastic surgeons using advanced tools and equipment.

Unlike standard reconstructive plastic surgery procedures, cosmetic surgery procedures exist to enhance a person’s appearance. (source)

Breast reduction is one of the procedures of cosmetic surgery. The procedure is performed by a plastic surgeon to reduce the size of the woman’s breasts.

In medical terms, a breast reduction procedure is known as reduction mammoplasty.

The breast reduction procedure removes excess fat from the breasts. The same procedure removes unwanted glandular tissues across the breast area, including the unwanted skin.

The same procedure fixes the position of the nipples as per the woman’s demand.

Does Medicare Cover Breast Reduction

Medicare is the national health insurance program backed by the U.S. government.

People who are enrolled in this health care program receive medical treatment at subsidized rates.

Medicare is a national health insurance program in the U.S. designed to cover medically necessary services, generally excluding purely cosmetic procedures except under special circumstances. (source)

Medicare may cover breast reduction surgery if it is deemed medically necessary, such as to relieve symptoms like back pain, skin irritation, or other health issues caused by large breasts.

In some cases, if the breast reduction procedure is medically needed, then it may be covered by Medicare under certain conditions.

Your medical provider will provide documentation to show that the procedure is medically necessary, typically including evidence of chronic symptoms for at least 6 months and unsuccessful conservative treatments. (source)

You must provide proper evidence that the breast reduction is medically necessary; only then will Medicare provide coverage for the procedure. (source)

There have been cases against surgeons who provided false evidence to claim Medicare coverage for breast reduction and other cosmetic surgeries. (source)

How do I know if I am eligible for Breast Reduction surgery

To get coverage under Medicare for breast reduction, you need to provide documentation from a physician verifying that the surgery is medically necessary.

If breast reduction surgery is deemed medically necessary, only then will it be covered under the Medicare program.

According to Medicare’s guidelines, if a woman is experiencing any of the following conditions, she may be eligible for a breast reduction under Medicare coverage.

#1. Daily physical activities affected

Large breasts can put extra weight on the shoulders and other parts of the body, which restricts the woman from doing their physical activities properly.

If you feel heavier with large breasts and want to reduce their size and weight, then you should be eligible for the breast reduction treatment.

#2. Chronic back pain

Back pain is the most common issue that every woman with large breasts faces. Large breast causes persistent back pain as they put up extra weight on the shoulders and back area.

#3. Skin irritation

Large breasts require heavy-duty undergarments. Undergarments are made from different materials, which include wires and elastic equipment. This causes skin irritation.

#4. Skin infections

Large breasts cause excessive sweat as they cover up a large area of the chest. Excessive sweat due to large breasts creates skin-related problems i.e. skin infections.

If the skin infection becomes persistent, then you can go for breast reduction under Medicare.

Are there any Medicare billing codes for breast reduction?

The U.S. Medicare program does not use ‘item numbers’ for specific surgeries; instead, it uses standard procedure codes for breast reduction. (source) For breast reduction deemed medically necessary, Medicare uses specific procedure billing codes rather than separate item numbers.

CPT Code 19318 – Reduction Mammaplasty

CPT code 19318 is the procedure code for reduction mammaplasty (breast reduction) under Medicare. This code covers cases including those that involve surgical repositioning of the nipple, such as after breast cancer surgery or to correct a developmental breast abnormality.

In Medicare coding, any reduction mammaplasty (with or without nipple repositioning) is a surgical procedure covered under the same code, provided it meets medical necessity criteria.

A bilateral reduction mammaplasty (breast reduction on both breasts with nipple repositioning) to relieve persistent back and shoulder pain from large breasts is covered under Medicare’s breast reduction code as long as the surgery is medically necessary (e.g., to alleviate chronic pain). (source)

The Bottom Line:

Medicare Health Care Insurance is completely different from the health care insurance policies provided by private companies.

This health insurance policy provides coverage against all the major medical treatments at affordable rates.

Breast reduction can be considered a medically necessary procedure for some women with large breasts if specific symptoms or health issues are present.

However, the same procedure is covered by Medicare under certain conditions mentioned in the above article.

Study well about the Medicare insurance coverage, the conditions, and other related information before going for the breast reduction treatment.

See Also

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