Breast reduction, also often called Breast reductionDuring this surgery, skin and tissue are faraway from the breast and the breasts are then reshaped to a smaller size.
This form of surgery has increased for the reason that pandemic. Cosmetic breast reductions – those not deemed medically crucial and paid for out-of-pocket – increased 54% from 2019 to 2022, in keeping with the American Society of Plastic Surgeons (ASPS).
ASPS suggests that several aspects can have contributed to this trend, including an increased deal with health and fitness, telecommuting, and versatile work schedules that allow for easier recovery from surgery and more time to reflect on personal wellness and well-being.
Advantages of breast reduction Possible symptoms include relief from upper back, neck and shoulder pain, increased ability to exercise and take part in physical activities, and improved self-image.
Older women and breast reduction
Dr. Lynn Damitz, Head of Department of Plastic and Reconstructive Surgery and director of the division of aesthetic surgery on the UNC School of Medicine in Chapel Hill, North Carolina, and vice chairman of the ASPS Board of Directors for Health Policy and Advocacy, has observed an increasing number of ladies ages 65 and older undergoing breast reduction surgery.
“I’ve definitely seen an increase in the last two decades,” she says. “My patients over 65 are highly motivated. Often they’ve been thinking about the surgery for a long time and are ready to do something for themselves.”
The costs of a breast reduction
The cost of the operation could be significant. According to ASPS, the Average costs of a surgeon’s fee for a cosmetic breast reduction is $6,771. Other fees may include anesthesia and hospital or surgical costs, medical tests, prescriptions, and post-operative clothing.
“Although many women pay for the procedure out of their own pocket, private health insurance, Medicare and Medicare Advantage may cover the cost,” Damitz says.
How to qualify for Medicare and Medicare Advantage coverage for breast reduction
To qualify for Medicare or Medicare Advantage coverage for breast reduction surgery, you have to medically crucial, not cosmeticSpecifically, the intervention must be crucial:
- To reduce or eliminate symptoms related to breast size
- To reduce the scale of a breast, to make it symmetrical, with breast reconstruction after breast cancer surgery
Large breasts may cause quite a few unpleasant symptoms, including back pain, neck pain, heaviness, shoulder wrinkles, posture problems, neuropathic pain, numbness, discomfort on skin contact, rashes, skin conditions and hygiene problems.
“Before Medicare or Medicare Advantage insurance is considered, patients must have experienced a range of these symptoms,” says Damitz. In addition, Centers for Medicare and Medicaid Services (CMS) intimately these rules:
- Surgeons must be sure that patients have tried non-surgical procedures to alleviate chest pain or chafing, resembling chiropractic treatment, physical therapy and dermatological treatments
- The symptoms should have been present for no less than six months
- Interventions and medical treatment couldn’t sufficiently alleviate the symptoms
- The patient was informed concerning the risks of complications
- The notes indicate the planned amount of tissue to be removed and the explanations for this decision.
In addition, CMS rules state that the quantity of breast tissue to be removed have to be proportional to body surface area, based on a measurement called cord scaleSpecifically, it states: “If the person’s body surface area and the weight of the removed breast tissue are above the 22nd percentile, the surgical procedure is considered medically appropriate and necessary, taking into account the relevant criteria. If only one breast meets the Schnur scale criteria, breast tissue can be removed from the other breast to achieve symmetry.”
“This rule takes into account how disproportionate a person’s breasts are compared to the rest of the body,” Damitz says. If you are obese, chances are you’ll not meet the Schnur scale criteria, Damitz says.
Medicare and Medicare Advantage coverage of breast reduction
Only some surgeons accept insurance coverage for breast reductions. Damitz is considered one of them, and a significant slice of her breast reductions are covered by insurance. 29% of the breast reductions she performs are covered by Medicare and Medicare Advantage, she says.
The approval process could also be different for Medicare or Medicare Advantage plan members.
“Medicare does not offer prior authorization for breast reductions, but some Medicare Advantage plans do,” Damitz says. “This means that even if you think you qualify for Medicare coverage, you may choose to pay for the surgery up front and hope for Medicare reimbursement later,” she says. It’s necessary to notice, nonetheless, that if Medicare doesn’t reimburse you after the actual fact, these fees could be significantly higher than a pre-negotiated fee, Damitz says.
If the patient’s Medicare Advantage plan requires prior authorization, the associated fee of the surgery could also be paid up front.
“The criteria of each Medicare Advantage plan is different,” says Damitz. “It’s helpful for patients to contact their insurance company in advance and ask about the criteria. That way, if they haven’t tried all the non-surgical options they need, they can consider those first.”
As all the time with Medicare and Medicare Advantage insurance, deductibles and copayments may apply.
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