Does Medicare Cover Breast Reduction?

Some people think that breast reduction (or breast surgery in general) is only for cosmetic purposes.

And, sure, it does have some cosmetic benefits. Some people really do undergo breast surgery to improve their appearance.

But that does not mean that breast reduction surgery is not done due to medical reasons as well.

So a common question many people have is, “Does Medicare cover breast reduction?” In this article, we answer that question in clear, plain English. You will also find the average costs of breast reduction surgery and other helpful info.

Does Medicare Cover Breast Reduction?

The short answer is no. In most cases, Medicare will not cover the cost of breast reduction surgery. That said, there may be some situations where you can get these costs covered. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your breast reduction surgery.

Original Medicare (Medicare Part A and Part B) does not provide coverage for breast reduction surgery. That is because it is often considered a type of cosmetic surgery. So that means you will have to pay 100 percent for your breast reduction surgery.

However, in some cases, Medicare may provide coverage for your breast reduction surgery. But only if the operation is for medically necessary purposes.

Medicare will provide coverage for your breast reduction surgery after a mastectomy for breast cancer. However, for Medicare to provide coverage for your breast reduction surgery, your healthcare provider is must provide documents to Medicare. The documents should state that you will be having the surgery because of your mastectomy.

Medicare will also provide coverage for this operation if you have it to reduce pain due having a large chest. However, you will need to meet some conditions first before Medicare authorizes coverage for your breast reduction surgery. Those conditions consist of the following:

The purpose of the surgery is to treat your pain
You have tried other ways to treat it, but it has little to no effect
You have been living with the symptoms for at least six months

If you have a breast reduction surgery to treat your low self-esteem, Medicare will not provide coverage. Because, in this case, it is still considered cosmetic surgery rather than a medically necessary one.

When Medicare Part A, Part B or Medicare Advantage Pays the Bills

If you are having breast reduction surgery in an inpatient setting, Medicare Part A will cover it. You are usually admitted as an inpatient if you are having the surgery during or after a mastectomy.

Medicare Part B provides coverage for breast reduction surgery if you have it in an outpatient setting. Medicare Part B will cover 80 percent of the costs of your surgery. You will pay for the remaining 20 percent.

Medicare Advantage plans (Medicare Part C) also provide coverage for breast reduction. They cover everything Original Medicare covers as well as some additional benefits. However, exactly what it covers and how much the out-of-pocket costs are will vary depending on the specifics of your plan.

Breast Reduction Surgery Costs

The average cost of breast reduction surgery is about $6,000. This includes the fees for the surgeon, facility you get the procedure at and anesthesia.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.