Does Medicare Pay for Breast Reduction?

Medicare, the federal health insurance program, can provide coverage for breast reduction surgery, also known as reduction mammoplasty. This coverage is not automatic and depends entirely on the procedure being deemed medically necessary. Understanding the specific conditions under which Medicare might cover this surgery is important for beneficiaries considering the procedure.

Medicare Coverage Criteria

Medicare covers breast reduction surgery when there is a clear medical need, rather than for cosmetic reasons. One common medical reason is macromastia, where excessively large breasts cause significant physical symptoms. These symptoms often include severe and chronic pain in the neck, back, or shoulders, which can interfere with daily activities.

Medicare may cover the procedure if individuals experience recurrent skin irritation, rashes, or infections underneath the breasts that do not respond to medical management. Shoulder grooving with skin irritation is another symptom that may qualify for coverage. The presence of postural changes or skeletal deformities resulting from the weight of the breasts can also indicate medical necessity.

For coverage, medical documentation must demonstrate that these symptoms have persisted for at least six months. Non-surgical treatments, such as physical therapy, pain medication, or the use of supportive garments, must have been attempted and proven ineffective in alleviating the symptoms.

Medicare also considers breast reduction medically necessary to achieve symmetry following breast cancer surgery, particularly after a mastectomy. This involves reducing the size of a healthy breast to match a reconstructed breast.

The Approval Process

Obtaining Medicare coverage for breast reduction surgery involves a structured approval process that begins with a medical professional. Your primary care physician or specialist must certify that the surgery is medically necessary to address your specific symptoms.

You will consult with a plastic or reconstructive surgeon who will further evaluate your condition. The surgeon will prepare detailed medical documentation to support the medical necessity of the breast reduction. This documentation usually includes your medical history, findings from physical examinations, and sometimes photographic evidence of the physical issues caused by breast size.

This comprehensive documentation, including the surgeon’s letter of medical necessity, is then submitted to Medicare or your Medicare Advantage plan for pre-authorization or prior approval. The purpose of this step is to ensure that the procedure meets Medicare’s strict coverage criteria before it is performed. Medicare Advantage plans are required to cover everything Original Medicare covers, but their specific pre-authorization processes may vary.

During the review process, Medicare or your plan may request additional information to further assess the medical necessity of the surgery. Decisions regarding coverage are then communicated, indicating whether the procedure has been approved for reimbursement. It is important to obtain this approval before scheduling the surgery to understand your coverage.

Costs and Financial Considerations

Even when breast reduction surgery is approved by Medicare as medically necessary, beneficiaries will likely incur some out-of-pocket costs. Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance), both of which may apply depending on whether the surgery is performed as an inpatient or outpatient procedure. Most breast reduction surgeries are outpatient procedures covered under Part B.

For outpatient procedures, Medicare Part B covers 80% of the Medicare-approved amount after you meet your annual deductible. In 2025, the Medicare Part B deductible is $257. After this deductible is met, you are responsible for the remaining 20% co-insurance of the approved costs. The monthly premium for Medicare Part B in 2025 is $185 for most individuals.

If the surgery requires an inpatient hospital stay, Medicare Part A covers hospital costs after you meet its deductible. For 2025, the Medicare Part A deductible is $1,676 per benefit period. While Part A covers inpatient services, most people do not have co-insurance costs for short hospital stays associated with breast reduction.

Beneficiaries enrolled in a Medicare Advantage plan (Part C) will have their costs structured differently. These plans, offered by private insurance companies, must cover at least what Original Medicare covers, but they may have different deductibles, co-payments, and co-insurance amounts. Consult with your specific Medicare Advantage plan to understand your estimated financial responsibility.