Does Medicare Cover Breast Reduction Surgery? 

Breast reduction surgery, or reduction mammaplasty, is a surgical procedure that removes fat, breast tissue, and excess skin from large breasts to relieve symptoms like pain, discomfort, or disability. In some cases, this procedure is strictly for cosmetic purposes, but in others, it may be medically necessary to improve quality of life. 

If your health care provider has suggested that you get breast reduction surgery, you may have coverage through your Medicare insurance if you’re eligible. Here’s a look at when Medicare covers these types of procedures. 

When does Medicare cover breast reduction surgery? 

Medicare doesn’t cover breast reduction surgery if it’s only for cosmetic reasons. However, if you need breast reduction surgery because your breasts are excessively large and they are causing chronic health issues like pain, back pain, painful rash, open sores, or problems with posture, Medicare will cover your procedure.

To be eligible for this benefit, your physician must accept Medicare assignment and must certify the following:

• The procedure is medically necessary to treat your pain or health issue.
• You’ve tried other nonsurgical procedures, but they haven’t resolved your issues.
• You’ve had symptoms for at least six months. 

Medicare also covers breast reduction surgery after a mastectomy for breast cancer to improve breast symmetry, whether it’s a single or bilateral mastectomy. To be eligible for this procedure, your physician must provide documentation to Medicare certifying that your breast reduction procedure is because of your mastectomy. 

Medicare may also cover breast reduction surgery if you have breast hypertrophy, a condition that causes breast(s) to increase in size, weight, and density, and become painful. If your physician certifies that your breast reduction procedure is medically necessary because breast hypertrophy is the main cause of your pain and other health issues, Medicare will cover it. 

Original Medicare Part A (hospital insurance)may pay for breast reduction surgery if you have it while you’re a hospital inpatient. Your physician must formally admit you to the hospital, and the hospital must accept Medicare assignment. You are responsible for paying the Part A deductible for the current benefit period. If your inpatient stay extends beyond 60 days, you are also responsible for paying copayments to the hospital. 

Original Medicare Part B (medical insurance) may cover your breast reduction surgery if you have it as an outpatient in a hospital or medical facility that accepts Medicare assignment. 
Medicare Part B pays for 80 percent of the final approved cost, and you pay 20 percent. You must also pay your annual Part B deductible. 

If you are enrolled in a Medicare Advantage (Part C) plan, you have access to the same benefits as you’d have through Original Medicare Parts A and B if you’re eligible for the benefit. Many Medicare Advantage plans offer additional benefits as well. Your plan may require that you use physicians, hospitals, and outpatient medical facilities that are included in your plan’s network of providers to get coverage. You may also need to get a referral from your primary care physician to see a specialist or surgeon. 

The amount you pay for coinsurance or copayments depends on the type of Medicare Advantage plan you have. If you aren’t sure about the details, check with your plan provider before making medical arrangements.