Generally, Medicare does not cover breast reduction because doctors often categorize it as a cosmetic procedure rather than a medically necessary surgery.
However, Medicare does cover breast removal surgery, breast reconstruction, and prosthesis surgery as part of treatment for medical problems, such as cancer or fibrocystic disease.
Both original Medicare and Medicare Advantage provide coverage for medically necessary breast surgeries. Deductibles, copays, and coinsurance in the two programs differ.
Below, we discuss breast reduction surgery and coverage. Then, we look at breast reconstruction surgery and prosthesis. Lastly, we examine coverage and costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Because the goal of breast reduction often involves improving a person’s appearance, Medicare usually does not cover the procedure. Any type of cosmetic surgery is not on the list of Medicare-approved surgeries.
However, Medicare coverage may be available when the procedure is needed to correct Macromastia, which is a female health problem related to large breasts.
If a person has a breast reduction that Medicare does not cover, they must pay 100% of the costs.
Doctors use breast reduction surgery, sometimes called reduction mammoplasty, to reduce breast volume. When evaluating whether a person is a candidate for the procedure, doctors consider:
- medical history
- family history of breast cancer
- anticipated future pregnancies and breastfeeding
- general medical condition
- symptoms related to breast weight, such as back, neck, or shoulder pain
There are several types of breast reduction surgeries. All surgery carries risks.
Complications are common after breast reduction, but most of them are considered mild. Minor complications may include delayed wound healing and infection, while serious complications may involve the death of cells around the nipple or a major rupture of the surgical wound.
Medicare covers breast reconstruction surgery after removal of a breast for any medically necessary reason. Coverage includes reconstruction of the affected and the unaffected breast. In addition, Medicare covers the surgical implantation of a prosthesis on an inpatient or outpatient basis.
What is breast reconstruction surgery?
After a person undergoes a mastectomy, which is surgery to remove a breast, they may choose to have their breast rebuilt. Doctors do this with one of the following methods:
- use of implants
- use of tissue from another part of the body
- use of both of the above
Someone can undergo reconstruction surgery at the time of the mastectomy. They may also choose to wait until after the mastectomy incisions heal and the cancer therapy is completed, which can be months or years later.
At times, breast reconstruction surgery may include surgery on the unaffected breast, for the purpose of making both breasts the same size and shape.
All types of breast reconstruction surgery carry the risk of complications. Depending on the method, these may include:
- death of tissue
- blood clots
In recent years, the popularity of breast reconstruction surgery has increased. According to the Agency for Healthcare Research and Quality, the portion of people who chose to have the surgery following a mastectomy rose 65% between 2009 and 2014.
Medicare may not cover every kind of breast reconstruction surgery. For example, if the purpose of surgery is to create a more balanced appearance, it might not meet the criteria for coverage.
A person considering any type of breast surgery should check their Medicare plan to see if it covers the specific procedure.
For covered breast reconstruction surgeries, different parts of Medicare help with the expenses. A person with original Medicare, which includes Part A and Part B, gets coverage and may have additional help if they have Part D and Medigap. The alternative to original Medicare, which is Part C, also provides coverage. Details are shown below.
Part A, Medicare’s hospitalization insurance, covers inpatient surgeries. A person’s share of the costs would include a $1,408 deductible for each benefit period, and $0 coinsurance for the first 60 days of each benefit period.
A benefit period begins the day an individual enters a hospital and ends the day after they have been out of the hospital for 60 consecutive days.
Doctors perform some breast reconstruction surgeries on an outpatient basis, such as the implantation of a breast prosthesis following the removal of a breast for cancer.
Part B also covers some external prostheses, such as a postsurgical bra.
Part C, or Medicare Advantage, provides the coverage of Part A and Part B for breast surgeries. Advantage plans may also include prescription drug coverage and other extra perks.
The deductibles, copays, and coinsurance differ from those of Medicare parts A and B. To get lower costs, a person must go to in-network providers.
Advantage plans also put a yearly cap on expenses.
Part D is Medicare’s prescription drug coverage, available for those with original Medicare to purchase.
When a person undergoes breast surgery in a hospital, Part A covers any drugs they need. If an individual needs a prescription medication outside a hospital setting, their Part D plan would help pay for the cost.
Medigap is Medicare supplement insurance available for purchase to those with original Medicare. Medigap plans help pay some or all of the deductibles, copays, and coinsurance associated with parts A and B.
Medicare usually does not cover breast reduction surgery because, in most instances, it is a cosmetic procedure.
Coverage may be available when the procedure is needed to correct Macromastia.
However, both original Medicare and Medicare Advantage cover breast reconstruction surgery and the implantation of prostheses for a medically necessary reason, such as post-cancer treatment.
Any surgery carries risks, which can sometimes be serious. A person considering any kind of breast surgery may wish to discuss the potential benefits and risks with their doctor.
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