Does Medicaid Cover Breast Reduction

Does Medicaid Cover Breast Reduction?

Last Updated on February 27, 2022 by Anne-Sophie Reinhardt

There are questions left unanswered about Medicaid coverage that many people is asking. Does Medicaid cover breast reduction, and what is the requirements to be qualified?

Does Medicaid Cover Breast Reduction?

In some cases, Medicaid may pay for breast reduction. Medicaid will only approve your breast reduction procedure if deemed medically necessary and approved by an authorised physician. Your breast reduction must be related to a medical condition. If you seek a breast reduction for cosmetic reasons, Medicaid will not pay, and you will have to pay the entire amount personally.

Medicaid might recommend you consider other treatments, such as weight loss and physical therapy. If you have documentation from your doctor that shows neck and back pain, Medicaid will pre authorize surgery.

Along with other insurance programs, Medicaid requires a 500-gram breast reduction. Because of the low reimbursement rates, even if Medicaid is willing to pay for breast reduction surgery it may be difficult to find a surgeon.

Does Medicaid cover breast reduction?

How Can You Qualify for Medicaid’s Breast Reduction Coverage?

You will need to fulfil other conditions if you have a breast reduction. Your physician will verify this.

  1. You have not had success with non-surgical procedures.
  2. Your symptoms have been present for the past six months.
  3. This procedure can reduce your pain.

If you want to receive all benefits, your breast reduction must be done in a Medicaid-approved location. Before your first appointment, you can ask the doctor if they accept Medicaid. To find Medicaid-approved doctors, you can do online queries.

Which Breast Reduction Procedures Does Medicaid Pay for?

Mastectomy for Male Gynecomastia

Mastectomy for Gynecomastia is an operation that removes breast tissue from adult males. Male gynecomastia occurs when the male mammary glands grow too much.

Medicaid will cover mastectomy for males if they meet the following conditions:

  1. The adult recipient has a history that exceeds three months, even if pathological causes have been ruled.
  2. A teenager recipient has had gynecomastia for more than six years after any pathological causes have been ruled.
  3. The excess tissue mustn’t be fatty but glandular as determined by a mammogram.
  4. Prescriptions, alcohol or illegal drugs should not cause excess tissue growth.

Reduction Mammoplasty

Medicaid covers reduction mammoplasty for cases of genetic deficiency, loss of substantial contralateral female breast tissue due to trauma or other conditions. If the procedure is deemed necessary by a physician due to high cancer risk or cancer, it will be covered.

Prophylactic Mastectomy

Prophylactic mastectomy refers to the removal of the mammary cells to prevent cancerous growth in those who are at high risk of developing or redeveloping the disease.

Medicaid will cover prophylactic mastectomy if you meet the following conditions:

  1. If the recipient has had breast cancer in the past.
  2. A breast biopsy can reveal that the recipient is at high risk for breast cancer.

Breast Reconstructive Surgery

After a mastectomy, breast reconstruction can restore balance to the contralateral breast. Breast reconstruction includes the creation of a new breast mound and the rebuilding of the nipples.

If deemed necessary by a doctor, Medicaid will cover breast reconstruction. Documentation, including photographs, must be provided by the physician to confirm severe disfigurement caused by trauma, disease or other surgical complications.

Are There Any Out-Of-Pocket Costs for Breast Reduction?

Your out-of-pocket breast reduction costs can include monthly Medicaid deductibles. If specialists in an ambulatory surgery centre perform the procedure, these costs may be slightly higher.

According to studies, the average Medicaid beneficiary spends 279 USD on out-of-pocket expenses for breast reduction performed in an ambulatory facility, compared with 259 USD in an inpatient facility. This is not a specific estimate for breast reduction, but it covers all types of plastic and reconstructive surgeries.

What Can You Expect from Breast Reduction Surgery?

Before the Procedure

There will be several tests required to prepare for breast reduction. Your doctor will also need to conduct a routine breast exam. You may also need an ultrasound or mammogram.

These tests will allow the doctor to determine if breast reduction is necessary and if the patient is healthy enough for the procedure. Your doctor will ask you questions about your medical history, as well as the family’s. These questions will require you to be honest.

After your surgeon has cleared you to undergo surgery, there are several other steps that you need to follow.

  1. Prescription medication should be stopped at least two days before the surgery.
  2. If you are an avid smoker, quit smoking.
  3. You should limit your intake of water and food on the day you have surgery.

During the Procedure

To achieve the desired result, they will reconstruct your breasts. You can choose to have the procedure done inpatient or outpatient. General anaesthesia is or breast reduction surgery in the majority of cases.

After the Procedure

  • Firstly, they will place bandages on your breasts and might also attach drainage tubes. These tubes can drain fluids and reduce swelling.
  • So, the tubes and bandages will stay on for at least a few days. Then, after removing the bandages, you’ll need to wear a post-surgical bra for several weeks.
  • Many people feel fatigued and in pain after breast reduction surgery, making it challenging to do other tasks. So, they have to off work for a week or more and allow the body to rest and recuperate.
  • Lastly, the doctor will recommend medication to ease the pain. So, your doctor will advise you when you can return to work or do activities like lifting.

Medicaid Does Cover Breast Reduction…But…

If you meet all the above conditions, Medicaid will cover your breast reduction surgery. But again, Medicaid does not pay for breast reduction surgery. Depending on your Medicaid plan and the location of your breast reduction, there may be some out-of-pocket costs.

If you have the same questions about breast surgery covered under Medicaid, find out more at!

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