Generally, Medicare does not cover breast reduction. This is because doctors often categorize it as a cosmetic procedure rather than medically necessary surgery.
However, Medicare does cover breast reduction surgery, also known as reduction mammoplasty, when excessively large breasts cause chronic medical problems, such as pain or postural changes.
Both original Medicare and Medicare Advantage provide coverage for medically necessary breast surgeries. However, the deductibles, copays, and coinsurances differ between the two programs.
Below, we explain what breast reduction surgery is and when and how Medicare covers the 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.
When the purpose of breast reduction surgery is purely cosmetic, such as when a person wants to reduce the size of their breasts only for aesthetic reasons, Medicare does not cover the procedure.
Medicare will pay for breast reduction surgery for those who experience medical side effects due to excessively large breasts.
Some examples of medical circumstances in which Medicare may pay for reduction surgery include:
- chronic skin infections under the breast tissue
- postural changes resulting from very heavy breasts
- severe back, neck, or shoulder pain due to excessively large breasts
A person’s doctor would need to certify the surgery is medically necessary for Medicare to cover the surgery. A person may need to prove that they have been experiencing symptoms for at least 6 months and that nonsurgical treatments have not been effective.
If a person desires breast reduction as a part of gender-affirming interventions, Medicare’s decision on whether to cover the surgery will be on a local Medicare Administrative Contractors (MAC) basis. A person will need to contact Medicare to find out how their local MAC may cover gender-affirming surgeries.
According to a 2020 study in Plastic and Reconstructive Surgery, the average outpatient cost of breast reduction is $9,077, while the average inpatient cost is $19,975. If a person wants a breast reduction procedure that Medicare does not cover, they must pay 100% of the cost.
For breast reconstruction surgeries that meet the coverage criteria, different parts of Medicare help cover 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, Part C, also provides coverage.
Part A
Part A, Medicare’s hospitalization insurance, covers inpatient surgeries. A person’s share of the costs would include a $1,484 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.
Part B
Doctors perform some breast reconstruction and reduction surgeries on an outpatient basis, such as the implantation of a breast prosthesis following the removal of a breast due to cancer.
In these instances, Medicare Part B, which is medical insurance, provides coverage. A person will need to pay a share of the costs, including 20% of the Medicare-approved amounts and the $203 yearly deductible.
Part B also covers some external prostheses, such as a postsurgical bra.
Part C
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, copayments, 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
Part D is Medicare’s prescription drug coverage, and it is 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 will help pay for the cost.
Medigap
Medigap is Medicare supplement insurance that is available to those with original Medicare. Medigap plans help pay some or all of the deductibles, copays, and coinsurance associated with parts A and B.
Out-of-pocket costs
Out-of-pocket expenses for breast reduction surgery can include deductibles, copayments, and coinsurances. Out-of-pocket costs tend to be slightly higher when doctors perform the procedure at an ambulatory surgery center.
Research shows that the average person pays $279 in out-of-pocket expenses for plastic and reconstructive surgery at an ambulatory surgery center, compared with $259 at an outpatient hospital. However, this is an estimate for all types of plastic and reconstructive surgery, not breast reduction surgery specifically.
Doctors use breast reduction surgery, sometimes called 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. As with all surgery, each of these procedures carries risks.
Complications are common after breast reduction, but most tend to be mild. Minor complications may
A person considering any type of breast surgery should check their Medicare plan to see whether it covers the specific procedure.
Medicare usually does not cover breast reduction surgery because, in most instances, it is a cosmetic procedure.
However, Medicare may cover breast surgery for a medical reason, such as when excessively large breasts cause pain or negatively affect a person’s daily life. A doctor must certify that the surgery is medically necessary, and Medicare coverage may depend on what a person’s MAC covers.
Any surgery carries risks, and these can sometimes be serious. A person considering any kind of breast surgery may wish to discuss the potential benefits and risks with their doctor.