Does Medicare Cover Breast Reduction Surgery?
Key takeaways:
Breast reduction surgery, also known as reduction mammoplasty, is a procedure that removes excess breast tissue.
Medicare covers breast reduction surgery when it’s deemed medically necessary. This includes surgery to relieve back and/or shoulder pain, as well as to create symmetry when a breast is reconstructed after cancer surgery.
Typically, breast reduction surgery is an outpatient procedure covered by Medicare Part B. After you meet your Part B deductible, original Medicare covers 80% of breast reduction surgery costs, while you pay 20%. Medicare Advantage plans also cover breast reduction surgery.
Table of contents
Breast reduction surgery is the commonly used name for reduction mammoplasty. Original Medicare covers breast reduction surgery when it’s deemed medically necessary. Medicare Advantage plans also cover the procedure.
Breast reduction surgery is considered medically necessary when it’s performed to relieve back and/or shoulder pain or to create symmetry when a breast is reconstructed after cancer surgery.
Breast reduction surgery can address several types of situations, such as:
Macromastia: Macromastia, also known as breast hypertrophy, is the development of breasts that are large in relation to a person’s size. The weight and size of the breasts can cause physical pain, emotional distress, and reduced quality of life.
Gigantomastia: This rare condition causes some women to develop excessively large breasts. Gigantomastia is often a result of puberty, pregnancy, or certain medications.
Breast reconstruction following mastectomy: This may mean creating symmetry with the reduction of one breast, following the other breast being reconstructed after cancer surgery. Or it may involve the reduction of both breasts following cancer surgery on one or both breasts.
Gynecomastia: Gynecomastia is breast tissue enlargement or overdevelopment in males.
Chest masculinization: Chest masculinization, or top surgery, is tissue removal for the purpose of gender affirmation.
Cosmetic surgery: In some cases, breast tissue is reduced solely for appearance purposes, though this is typically not covered by Medicare.
Is breast reduction surgery covered by Medicare?
Yes, Medicare covers breast reduction surgery, but only if the procedure is deemed medically necessary. This is true for both original Medicare and Medicare Advantage.
If you’re planning to have a breast reduction, your surgeon may need you to have a mammogram to look at your breast tissue before the procedure. Medicare covers screening mammograms once a year for women 40 and older and diagnostic mammograms more frequently (if medically necessary). You should talk to your surgeon about how your mammogram will be coded to make sure the test will be covered.
When does Medicare pay for breast reduction surgery?
As mentioned, Medicare covers a breast reduction if it’s medically necessary. This usually means the surgeon removes the minimal amount of tissue needed to relieve symptoms, not to achieve cosmetic results.
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In order for Medicare to cover your breast reduction surgery, you need to have been diagnosed with or have experienced one of the following symptoms, conditions or circumstances:
Skin changes such as inflammation, infection, bleeding, chronic moisture, and/or rashes
Shoulder grooving with skin irritation even when wearing an appropriate bra or other support garment
Back, neck, and/or shoulder pain that has interfered with daily activities for at least 6 months
Significant arthritic changes in the spine that have interfered with daily activities for at least 6 months
Breast reconstruction for one or both breasts following a medically necessary mastectomy
How much will different Medicare plans cover?
With any Medicare plan, you may be required to get a letter of medical necessity from your healthcare professional (part of the prior authorization process) in order for your breast reduction surgery to be covered.
If you have original Medicare, the amount your plan covers will depend on the type of facility you choose. According to Medicare’s procedure price lookup tool for outpatient procedures, the cost of a breast reduction at a hospital outpatient department is twice as much as at an ambulatory surgery center. This, in turn, could double your out-of-pocket costs, which we will discuss later.
Medicare also covers costs other than the actual procedure, such as outpatient medical supplies. For instance, you may be able to get reimbursed for a surgical bra after your breast reduction surgery.
If you have Medicare Advantage, your plan should match or exceed what original Medicare covers.
Medigap coverage
If you have original Medicare, you may also have a Medigap supplement insurance plan. Depending on which plan you have, Medigap may cover all or part of your out-of-pocket costs, which we will discuss next.
Out-of-pocket costs
As mentioned, a breast reduction could cost twice as much at a hospital than at an ambulatory surgery center. Since breast reduction surgery is typically an outpatient procedure, you will be responsible for meeting your Part B deductible before your plan will cover any costs.
The chart below provides a sample of national cost averages for breast reduction surgery for original Medicare enrollees.
Ambulatory surgical centers | Hospital outpatient departments | |
Surgeon fee | $1,108 | $1,108 |
Facility fee | $2,408 | $5,943 |
Total | $3,516 | $7,051 |
What Medicare covers | $2,813 | $5,641* |
What you pay | $703 | $1,410* |
*Note: A rounding error on the Medicare site shows different numbers.
If you have Medicare Advantage, your out-of-pocket costs may be more or less than the above, depending on your plan. You can find out about your estimated cost-sharing for the procedure by looking for pricing information on your plan’s website or by contacting your plan by phone.
Keep in mind that there may be out-of-pocket costs related to the procedure and your recovery, beyond what’s listed above. These expenses may include:
Medications
Transportation to and from appointments
Lost income from time off from work
Child care
Medigap out-of-pocket costs
There are multiple types of Medigap plans, all of which offer different benefits. The Center for Medicare & Medicaid Services offers this Medigap comparison table to help you understand the coverage provided by each kind of plan. For instance, every plan covers all or some of your Part B coinsurance or copayment. Only Plan C and Plan F, which are no longer available to new enrollees, cover Part B deductibles.
The bottom line
Breast reduction surgery can resolve medical conditions related to excessive breast tissue and help people who have had surgery for breast cancer regain symmetry. Medicare and Medicare Advantage plans cover breast reduction surgery for these purposes, among others, which are considered medically necessary. You may need a letter of medical necessity for your procedure to be covered, however.
Breast reduction surgery is typically an outpatient procedure covered under Medicare Part B. After you meet your Part B deductible, original Medicare covers 80% of your breast reduction, and you pay the other 20%. Your financial responsibility will depend on the specifics of your plan if you have Medicare Advantage. Health plan price transparency information can help you determine your estimated Medicare Advantage cost-sharing for the surgery.
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References
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Cleveland Clinic. (2022). Gigantomastia.
Manahan, M. (n.d.). Breast reduction surgery. Johns Hopkins Medicine.
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Medicare.gov. (n.d.). Cosmetic surgery.
Medicare.gov. (n.d.). Mammograms.
Medicare.gov. (n.d.). Outpatient medical & surgical services & supplies.
Medicare.gov. (n.d.). Surgery.
Murez, C. (2023). Breast reduction? Body weight a factor in healing time, study finds. U.S. News & World Report.
Nguyen, N. J., et al. (2021). Idiopathic gigantomastia in a patient on polypharmacy. BJR Case Reports.
Sachs, D., et al. (2023). Breast reduction. StatPearls.
White, A. G., et al. (2023). Reduction mammaplasty in younger patients: An evidence-based approach to treatment. Plastic and Aesthetic Nursing.
Yale Medicine. (n.d.). Breast hypertrophy.
