Breast reduction surgery, or reduction mammaplasty, involves removing excess skin and tissue from the breasts to reshape them into a smaller size. This procedure has gained popularity, especially since the pandemic, due to a variety of factors influencing personal health and aesthetic choices.

Rising Demand for Breast Reduction Surgery

Cosmetic breast reduction surgeries, which are not deemed medically necessary and are paid for out of pocket, increased by 54% from 2019 to 2022, according to the American Society of Plastic Surgeons (ASPS). The ASPS suggests this trend is driven by a heightened focus on health and fitness, the flexibility of remote work facilitating recovery, and more time for self-reflection regarding personal comfort and well-being.

Health Benefits of Breast Reduction Surgery

Breast reduction surgery can significantly improve quality of life. Benefits include relief from chronic pain in the upper back, neck, and shoulders, enhanced ability to engage in physical activities, and an improved self-image.

Older Women Seeking Relief

Dr. Lynn Damitz, chief of the Division of Plastic and Reconstructive Surgery and Director of Aesthetic Surgery at the UNC School of Medicine in Chapel Hill, NC, and ASPS board vice president of health policy and advocacy, notes a growing number of women aged 65 and over opting for breast reduction surgery.

“I’ve definitely seen an increase in the last two decades,” Dr. Damitz says. “My patients over 65 are highly motivated. Often, they have been thinking about doing the surgery for a long time and are ready to do something for themselves.”

Cost of Breast Reduction Surgery

The financial aspect of breast reduction surgery can be considerable. The ASPS states that the average cost of a surgeon’s fee for cosmetic breast reduction is $6,771. This figure excludes additional costs such as anesthesia, hospital or surgical facility fees, medical tests, prescriptions, and post-surgery garments.

Medicare and Medicare Advantage Coverage

While many women choose to pay for the procedure out of pocket, it is possible for breast reduction surgery to be covered by commercial insurance, Medicare, or Medicare Advantage if deemed medically necessary. To qualify for coverage, the surgery must aim to alleviate health problems caused by large breasts or to make a breast symmetrical with one reconstructed after breast cancer surgery.

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Qualifying for Medicare Coverage

To get Medicare or Medicare Advantage to cover breast reduction surgery, certain criteria must be met:

• Medical Necessity: The surgery must be necessary to reduce or eliminate symptoms such as back and neck pain, shoulder grooving, posture issues, skin rashes, and neuropathic pain.
• Non-Surgical Interventions: Patients must have tried non-surgical treatments like chiropractic care, physical therapy, or dermatologic treatments without adequate relief.
• Duration of Symptoms: Symptoms must have persisted for at least six months.
• Documented Tissue Removal: The amount of tissue to be removed must be proportional to the patient’s body surface area, determined using the Schnur scale.
• Risk Notification: Patients must be informed of the potential risks and complications.

Navigating Medicare Coverage

Only some surgeons accept insurance for breast reduction surgery. Dr. Damitz, who does accept insurance, reports that 29% of her breast reduction surgeries are covered by Medicare and Medicare Advantage. However, the approval process varies between Medicare and Medicare Advantage plans.

“Medicare doesn’t offer prior approval of breast reduction surgery, but some Medicare Advantage plans do,” says Dr. Damitz. This means that patients might have to pay upfront and seek reimbursement later if they are covered under Medicare. In contrast, some Medicare Advantage plans might pay for the surgery fees upfront after prior approval.

Planning Ahead

Patients should contact their insurers in advance to understand the specific criteria and ensure they have tried all prerequisite non-surgical options. As with all Medicare and Medicare Advantage coverage, deductibles and co-pays may apply.

Breast reduction surgery can be life-changing, especially for older women experiencing chronic discomfort. Understanding Medicare and Medicare Advantage coverage requirements can help patients make informed decisions about their health and well-being.

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