Medicare provides benefits for breast reduction surgery, also known as reduction mammoplasty, when it is medically necessary to treat macromastia or breast hypertrophy that is causing adverse health effects. Women experiencing this condition typically suffer from back and neck pain, headaches and skin problems. Two basic conditions apply for Medicare benefits: the condition must be present for at least six months and non-surgical medical intervention has failed to alleviate the symptoms. If the breast reduction surgery is considered cosmetic in nature, Medicare will deny a claim for benefits.
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Medicare Rules For Mammoplasty
Although Medicare will cover breast reduction surgery if medically necessary, Medicare will not give prior authorization for the surgery. A prerequisite for claiming benefits is that the surgery has already been performed. However, Medicare has issued some guidance regarding when such claims will be accepted and what conditions will result in a denial. The guidance is found in documents called Local Coverage Determinations, or LCD, which are issued for various medical procedures. The most recent LCDs issued regarding mammoplasty are called the "LCD for Mammoplasty, Reduction" and "LCD for Plastic Surgery." Copies of all Medicare LCDs can be found on the government website Centers for Medicare & Medicaid Services, or CMS.
There are several conditions set forth in the Medicare LCD for mammoplasty that are used to indicate when surgery is considered reasonable and necessary. The first condition concerns persistent back pain attributable to the macromastia that cannot be relieved by the use of conservative pain relievers, supportive garments or physical therapy. This also includes any significant restriction in physical activity. The second condition concerns skin problems, such as infections under the breasts that cannot be relieved. The third condition concerns skin irritation from shoulder grooving due to a supportive garment. If these conditions persist for more than six months and cannot be relieved by non-surgical means, then Medicare may provide benefits for breast reduction surgery to alleviate the symptoms.
Effect of Non-Surgical Interventions
In order to ensure that a Medicare claim for breast reduction surgery will be accepted, other non-surgical intervention must be shown to be ineffective in relieving the symptoms cause by the macromastia. The first area to address in this regard is whether the macromastia is caused by an active endocrine or metabolic process that can be treated with medication. Other areas to address are the use of garments to alleviate symptoms, engaging in physical therapy and, in the case of skin problems, the use of customary dermatological remedies.
If you have followed the Medicare guidance in an attempt the alleviate the symptoms suffered from macromastia—to no effect—and have gone through with breast reduction surgery, the next step in obtaining approval for Medicare benefits is to submit a claim. The Medicare LCD provides a list of supporting documentation and information necessary to receive claim approval, including the type of information that should be in the records. Although your physician should be familiar with these guidelines, it is important to note that the Medicare LCD specifies that the records show all of the non-surgical intervention and therapies that were used to alleviate your symptoms. It is clear that Medicare will not approve a claim for benefits for breast reduction surgery unless every effort was made to avoid surgery.
Medicare and Your Doctor
If you are considering seeking medical intervention that may include breast reduction surgery and intend to submit a claim to Medicare for the expenses, including surgery, you should verify with your doctor whether or not she will accept you as a Medicare patient. Some doctors will not offer breast reduction surgery to Medicare patients because of its rules and the claims process that follows surgery.