When to Use Medicare to Cover Breast Reduction Surgery in Texas

Recently, more people have been undergoing breast reduction surgery either for relief from physical discomfort or to improve their body image.

With advances in medical techniques, the surgery is safer, and recovery periods are much shorter, adding to the popularity of this type of surgery.

In many cases, insurance coverage can make a big difference in surgery accessibility for both women and men with gynecomastia. 

However, the process of insurance coverage, particularly with Medicare and Medicare Advantage, is sometimes very complex.

This article helps you get a head start on how insurance may or may not cover breast reduction.

The Rise in Breast Reduction Surgeries Since the Pandemic

Breast reduction surgeries increased considerably after 2020. Cosmetic breast reductions jumped 54 percent from 2019 to 2022, according to the American Society of Plastic Surgeons. 

The surge was partly because there was more emphasis on health during the remote work. Flexible schedules allowed for easy recovery after surgeries, and more people had time to think about their comfort.

Besides that, patients wanted to rid themselves of the kind of discomfort caused by having very big breasts. Gynecomastia causes back and neck pains, which sometimes make daily living complicated.

Symptoms That Qualify For a Medical Breast Reduction

To get insurance coverage, a patient will need documentation from a physician about the treatment of the persistent symptoms. Moreover, the symptoms have to last for more than 6 months. 

Even though symptoms can vary from person to person, the most commonly experienced problems are because of disproportionately large breasts. The symptoms include:

• Headaches
• Pain in the neck, back or shoulder
• Kyphosis or curved spine
• Shoulder grooving from bras
• Infection, rashes, and skin irritation

Benefits of Breast Reduction Surgery for Older Women 

Older women, particularly those over the age of 65 years, appreciate the overall health benefits of undergoing a breast reduction. Many are relieved of chronic upper back, neck, and shoulder pain due to large breasts.

Another important advantage relates to mobility. Patients very often find that exercise or physical activities are much easier for them following surgery, and this, again, can have a direct effect on their quality of life.

Reduction mammoplasty also improves self-esteem in many women who often feel peculiarly limited by the shape of their body. The procedure gives them the freedom to wear clothes they previously avoided and feel more confident in social gatherings.

The Cost of Breast Reduction Surgery  

Breast reduction surgery costs differ from one plastic surgeon to another in Texas. The only certain way of determining how much you will pay is by making an appointment for consultation with your specialist.

“For self-pay patients, it is quite important to consider ancillary expenses of post-surgery garments and prescription drugs needed during the recovery period. Many patients get blindsided by those extra charges,” says Dr. Olivier Deigni, of Deigni Plastic Surgery.

Some women, if their surgery can be justified as medically necessary rather than cosmetic, may be able to get insurance that covers the cost. This can greatly lower the expense.

Medicare and Medicare Advantage for Breast Reduction

Patients may be eligible under Medicare or Medicare Advantage for reduction mammoplasty, provided that the procedure is medically necessary. Chronic pain in the back, neck, or shoulder may determine this in most instances.

In most cases, insurance providers require that nonsurgical options, such as physical therapy, be tried first to alleviate symptoms. Providers want assurance that these methods did not provide adequate relief before surgery can be approved.

Different rules apply depending on whether one uses original Medicare or has a Medicare Advantage plan. So, check specific criteria with your provider in advance to avoid unexpected financial burdens later on.

Cosmetic Vs Insurance Breast Reduction

Breast reduction surgery is a multi-purpose treatment. If you are trying to reconstruct then the procedure will remove the extra tissues to reduce the pain or irritation and get you the comfort your body needs.

This helps the person deal with their daily activities easily and engage in exercise. However, some patients are also looking for an aesthetically pleasing result that complements their body.

But, you have to understand that your aesthetic goals will qualify for insurance coverage. Insurance providers need a minimum amount of tissue removed from both breasts to qualify for insurance coverage, which might not happen for the aesthetic results you are looking for.

If you want to have the cost covered, insurance carriers will investigate your case to make sure the procedure is medically necessary. 

It takes around six months to prepare and this includes consulting with the healthcare providers and looking for alternative methods of treatment.

The insurance companies will need letters on the medical professional’s letterhead before approving for surgery, stating that you have tried other methods for your conditions, but the surgical treatment is necessary to resolve your symptoms.

Important Steps for Insurance Approval

Approval for breast reduction surgery in Texas often requires patients to meet several medical criteria. Providers usually need documented proof of symptoms, such as pain or skin conditions related to large breasts.

Patients must try non-surgical treatments like chiropractic care or physical therapy before insurance companies consider covering the procedure. The goal is to show that these options did not resolve their issues.

Surgeons will also provide detailed documentation about how much tissue needs removal based on the patient’s body size and condition. This step is critical for satisfying insurance guidelines like the Schnur scale requirements.

Physical Examination Will Document the Following To Get Insurance Coverage

To get the insurance coverage, a physical examination will be conducted, which will look for a few things like:

• Significant grooving on the shoulder or ulceration of the shoulder or skin.
• Breast hypertrophy is necessary.
• They measure the size of the nipple and compare it with the height of the person.

Wrapping Up!

To get approval for breast reduction surgery and cover it under insurance, you will have to provide the necessary documentation and proof that you have tried other alternative methods for at least a period of six months to solve the problem but failed.

So, when you discuss the matter with an insurance agent, make sure you have all the documents handy.

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