How Long Does It Take Medicaid To Approve Breast Reduction >From alleviating back pain, to increasing comfort and mobility, it’s clear that a breast reduction can offer a number of health benefits. Perhaps equally as enticing, the procedure can also reshape your physical appearance in tangible and nearly immediate ways. If you’re like most patients, the natural next step will be to begin researching your options for finding a surgeon that best meets your individual needs while also remaining within your desired budget limit.
The word ‘sacrifice’ means to make a great personal effort or to give up something of great value. While, there is nothing that we should be willing to sacrifice in life, sometimes a big decision has to be made in our lives which will set us back financially, physically and emotionally. A million-dollar question that comes to mind when I hear people saying they want to get the surgery is how long does it take Medicaid to approve breast reduction?
For example, if you need to get your diabetes under control or take care of other health problems first, then it will take longer than two weeks to get approved for Medicaid and have your surgery scheduled—but still much less than the typical year-long wait time that some patients experience without Medicaid coverage.
How Long Does It Take Medicaid To Approve Breast Reduction
An average woman who wants smaller breasts because they’re too large may still be able to get her procedure covered by insurance if it’s performed by a qualified doctor who writes a letter justifying the need for the procedure.
The program is administered by the states, which set their own eligibility requirements and may choose whether to cover breast reduction surgery. Some states cover breast reduction surgery, while others do not. Those that do not cover breast reduction as part of their Medicaid program will provide a referral to another agency that does cover it.
It’s important to note that you will still have to pay all costs associated with your procedure upfront, and then submit an application for reimbursement after the fact through your state’s Medicaid office, even if approval comes quickly
4) Fill out the rest of the fields: your age and gender, whether you want to add on liposuction to reduce fat deposits around the breasts, and if you’d like any additional services such as laser treatment or nipple repair (which may require additional surgeries).
The Blue Cross Blue Shield Breast Reduction Calculator is a free, online tool that helps you determine whether you would be a good candidate for breast reduction surgery. The calculator incorporates the information about your height, weight, body mass index (BMI), and bra cup size to calculate your Body Surface Area (BSA). This number is then used to determine whether or not you are a suitable candidate for breast reduction surgery.
A breast reduction can be a life-changing procedure for women who are suffering from large and heavy breasts. Large breasts can cause back pain, neck pain and shoulder pain. They can also cause the skin to stretch, leading to sagging.
Medicare Breast Reduction Requirements
Medicare will only cover breast reduction surgery when it is deemed medically necessary by your doctor. Medically necessary situations generally include, pain, skin chafing, and infections or reconstruction after a mastectomy.
Generally, Medicare needs to consider your procedure medically necessary for it to be covered. This means that your breast reduction needs to be related to a medical condition. If your reduction is cosmetic, meaning it’s only meant to enhance your appearance, Medicare won’t pay.
Continue reading to learn when Medicare will cover breast reduction surgery, rules for eligibility, cost considerations, and more.
Will Medicare pay for a breast reduction?
Whether or not Medicare will cover breast reduction depends on your reason for having the surgery. There are several common reasons you might want or need a breast reduction, including:
- Reconstruction after a mastectomy for breast cancer. After a mastectomy, you may want to have surgery to reconstruct your breasts or to improve their symmetry. For example, if you had a single mastectomy of one breast, you may want surgery to make your breasts match again. Reconstruction can also be done if you had a bilateral mastectomy (or double mastectomy) of both breasts.
- Reducing pain caused by having a large chest. Having a larger chest can cause pain in the neck, back, and rib cage. You can also experience poor posture, which can lead to more pain. Your doctor might recommend breast reduction surgery to relieve this type of pain.
- Improving your overall appearance and self-esteem. You might choose to have breast reduction surgery because you’re unhappy with the size of your breasts. Breast reduction can sometimes help you have a more youthful appearance or balanced figure.
Medicare only pays for breast reduction for the first two reasons. In both of these situations, the breast reduction is considered medically necessary, so Medicare will cover it.
If you’re in the third situation, Medicare would consider your surgery cosmetic and would not cover it. You’d need to pay for 100 percent of the costs out of pocket.
If your self-esteem is being seriously affected by the size or shape of your breasts, talking to a licensed therapist might be helpful. Medicare does cover mental health services under Part B (medical insurance).
You can get counseling appointments covered and work with a professional on the best way to address how your body is affecting your self-esteem.
How do I qualify for coverage?
You’ll qualify to have your breast reduction covered if you meet Medicare’s conditions.
In the case of breast reduction for reconstruction after a mastectomy, Medicare will cover the procedure. Your doctor will just need to provide documentation to Medicare that you’re having breast reduction because of your mastectomy.
If you’re having breast reduction for pain, you’ll need to make sure you meet a few more conditions. Your doctor will need to verify that:
- the surgery is necessary to treat your pain
- nonsurgical procedures haven’t worked for you
- your symptoms have lasted at least 6 months
In some cases, your pain might be caused by a specific condition of the breasts called breast hypertrophy (or gigantomastia). Hypertrophy causes the breasts to increase in weight and density, causing pain and other problems.
Medicare will pay for breast reduction in the case of hypertrophy, as long as your doctor states that it is the primary cause of your pain or other symptoms.
You’ll need to get your breast reduction performed at a facility that accepts Medicare to receive full benefits. You can ask your surgeons if they accept Medicare before your first visit. You can also search for providers using the Medicare website.
If you have a Medicare Advantage (Medicare Part C) plan, you might also need to make sure the surgeon and facility you want to use is in network. You can search for surgeons within your plan’s network, contact your plan directly, or ask your surgeon’s office if they accept your plan.
What is not covered?
Medicare does not cover any cosmetic surgery procedures. This means that if your procedure is elective and for appearance only, you’ll pay 100 percent of the costs.
This is true no matter what kind of Medicare plan you have. Neither Advantage plans nor Medigap plans offer additional coverage for cosmetic procedures.
What are the out-of-pocket costs for covered procedures?
The costs you’ll pay for your breast reduction depend on the type of Medicare plan you have and the facility where you have your surgery. You’ll be covered no matter which plan you have, as long as your reduction is medically necessary.
Medicare Advantage plans are required to cover everything that Medicare parts A and B (original Medicare) cover. However, the cost you’ll pay might be different from plan to plan.
Medicare Part A
If you have original Medicare and are admitted as an inpatient for your breast reduction, it will be covered under Medicare Part A.
There are many reasons you may need to be admitted for this procedure, including concerns of possible complications. This may also be the case if you’re having breast reduction at the same time or just after a mastectomy.
When you use Part A, you’ll be responsible for the Part A deductible. The Part A deductible in 2020 is $1,408. You’ll need to pay this amount before your coverage kicks in. You might have already paid into your deductible if you’ve already used other Part A services, such as other hospital stays or home health care visits.
You won’t have any copay costs for days spent in the hospital until you reach your 60th day. Most people don’t need more than a few days in the hospital for a breast reduction. However, you should know that starting on day 61, you’ll pay $352 a day in coinsurance. If you reach 91 days, you’ll pay $704 per day in coinsurance for a total of 60 lifetime reserve days.
Medicare Part B
Your breast reduction will be covered under Medicare Part B if you have an outpatient procedure and are using original Medicare. Outpatient procedures can be done at hospitals or stand-alone surgical centers.
The Part B deductible is $198 in 2020. However, you’re also responsible for 20 percent of the cost of Medicare-approved procedures once you meet your deductible.
So, for example, if the Medicare-approved amount for your breast reconstruction was $6,000, Medicare would pay $4,800 and you’d pay $1,200.
Part B also has a monthly premium. In 2020, the premium is $144.60 for most people.
Medicare Part C
Medicare Part C is also known as Medicare Advantage. Medicare Advantage plans are offered by private companies that contract with Medicare. They offer the same coverage as original Medicare and often include extras such as vision or dental coverage.
Your breast reduction costs under Medicare Advantage will depend on your plan. You’ll generally have copays for procedures or hospital stays. You can call your plan ahead of the procedure to ask about costs, if you’re unsure how much they’ll cover.
Remember that no plan pays for elective cosmetic procedures. You’ll need to pay the full cost in that case. The cost can vary depending on the surgeon you choose, but a 2019 survey found that the average cost for breast reduction surgery in the United States was $5,475.
What should I expect from breast reduction surgery?
Your doctor will advise you how to prepare for breast reduction in a way that addresses your specific needs. However, there are some general things you can expect.
Before surgery
Your preparation for surgery will likely include a few different exams. Your doctor will need to perform a routine breast exam, and you might also need a mammogram and other lab work.
These tests will help your doctor figure out if you’re a good candidate for breast reduction and if you’re healthy enough for surgery.
Your doctor will also ask you questions about your medical history and your family’s medical history. It’s important to answer these questions honestly.
Once your doctor has cleared you for the procedure, you’ll need to take a few other steps to prepare. These might include:
- stop taking some over-the-counter pain medications a few days before surgery
- quit smoking if you’re smoker
- arrange a ride home and any care you might need after the procedure
- restrict or stop food and water on the day of surgery
Be sure to follow any specific instructions your doctor gives you to prepare.
During surgery
During the procedure, the skin, tissue, and fat of your breasts will be reconstructed to get the desired outcome. Your procedure might be inpatient or outpatient. Most people go under general anesthesia for breast reduction.
During recovery
Your breasts will be wrapped in bandages after surgery. You might also have drainage tubes attached to your breasts. These tubes help drain fluids and reduce any swelling.
You’ll typically keep your bandages and tubes on for several days. Once the bandages are removed, you’ll likely need to wear special post-surgical bras for a few weeks.
You can expect to take at least a week or two off work after your surgery to rest and recover. Most experience pain and tiredness after surgery, making it hard to do everyday activities.
You’ll be prescribed a medication to help manage pain. Your doctor can advise you on when you can get back to activities like lifting and exercise.
Your breasts might be swollen after your procedure. It might seem like they’re not smaller because of this, but you’ll notice the change once the swelling goes down and your body heals. Your doctor will set follow-up appointments to check on your progress.
It’s important to keep an eye on your stitches. If you notice any coming undone or any pus coming from the area, call your doctor immediately.
What are the long-term outcomes?
You’ll generally find that you feel better once the healing process is complete. If you were having neck or back pain before, you can expect some or all of that pain to be gone.
You might also need time to adjust to your new appearance and even feel depressed or anxious after your surgery. This is a common experience, but if these feelings persist, talk to your doctor about seeing a counselor for help.
You also might need to buy smaller clothes to fit your new body, especially if your breast size has changed drastically.
You’ll also likely have scars after your surgery. Your scars will fade over time, and you can improve healing by avoiding activities like lifting after surgery.
In some cases, you might need to have another surgery later on. This surgery can correct any complications or to revise the original surgery to improve your final outcome.
Medicaid Breast Reduction Approval
Medicaid covers breast reduction surgery to the unaffected breast if the other breast lacks or has lost tissue due to a genetic condition. Additionally, Medicaid covers breast reduction if the tissue loss was caused by an accident or cancer treatment.
Breast reduction surgery is another name for a procedure called reduction mammoplasty. During the procedure, surgeons remove excess fat and tissue from the breasts to reduce their size and weight. Breast reduction surgery can help relieve back pain, chafing or rash under the breasts and neck strain. It may also alleviate any psychological symptoms associated with having large breasts.
Although many women choose to have breast reduction surgery to relieve troublesome health symptoms, the surgery is sometimes performed for cosmetic purposes.
What is the Breast Reduction Surgery Cost Without Medicare?
However, this figure doesn’t include the costs of anesthesia, supplies or use of the hospital’s facilities. Therefore, the true cost of breast reduction surgery will most likely be significantly higher.
Does Medicare or Medicaid Cover Breast Reduction Surgery?
Getting a breast reduction covered by insurance like Medicare and Medicaid is unlikely due to aesthetic reasons. However, there are some circumstances in which they may provide coverage.
The eligibility criteria for Medicare and Medicaid breast reduction surgery coverage are complex, and it can be difficult to determine whether individual cases qualify without consulting a surgeon.
In What Cases will Insurance Cover a Breast Reduction Surgery?
So, how do you get a breast reduction covered by insurance? Medicare may cover breast reduction surgery if it’s deemed medically necessary. Medicare only considers covering beneficiaries who have experienced symptoms caused by their breast size for at least six months. Beneficiaries must satisfy at least one of the following criteria to meet Medicare’s definition of clinical necessity:
- Back or shoulder pain that interferes with normal activities and doesn’t improve with conservative treatments, such as weight loss or supportive garments
- Arthritic and progressive spinal conditions that don’t resolve with conservative management and cause ongoing symptoms or lifestyle constraints
- Intertrigo, or infection of the areas under the breasts, that doesn’t resolve with dermatologic treatment
- Skin irritation or damage caused by wearing garments to support the breasts
If Medicare agrees to cover breast reduction surgery, it’s unlikely to cover the removal of more breast tissue than is clinically necessary to provide symptom relief. In other words, it won’t cover the removal of extra tissue to achieve a desired cosmetic effect. It is impossible to say exactly how much breast tissue removal Medicare may cover, as this will depend on each person’s unique anatomy.
Some women request breast reduction surgery on a healthy breast to achieve symmetry if their other breast was reconstructed during cancer treatment. Medicare does not consider this type of breast reduction cosmetic, so it may provide coverage in this situation.
There are no coinsurance costs for the first 60 days after your initial admission. From days 61-90, you are liable for $400 coinsurance each day, rising to $800 for each lifetime reserve day from day 91 onwards.
Beneficiaries are responsible for paying all costs once their lifetime reserve days have been used up. Depending on your coverage level, Medicaid may cover deductibles and coinsurance if you are enrolled in both programs.
Does Medicaid Cover Breast Reduction Surgery?
Medicaid covers breast reduction surgery to the unaffected breast if the other breast lacks or has lost tissue due to a genetic condition. Additionally, Medicaid covers breast reduction if the tissue loss was caused by an accident or cancer treatment. Medicaid breast reduction criteria for coverage varies by state.
As of 2022, 12.3 million people were enrolled in both Medicare and Medicaid. This is known as dual-eligibility. If you’re eligible for both programs, you may be able to get most of your medical expenses covered if you qualify for breast reduction surgery coverage. In these cases, Medicaid pays for additional expenses once Medicare has covered what it will. These may include deductibles, coinsurance and Medicare Drug Coverage fees.