Breast reduction surgery, also known as reduction mammoplasty, is a procedure that involves removing excess breast tissue to reduce the size of the breasts. This surgery can be life-changing for individuals who experience physical discomfort and emotional distress due to large breasts. However, the cost of the surgery can be a significant barrier for some patients, especially those with low income. This is where Medicaid, a government-funded healthcare program, comes in to provide coverage for those in need.
Medicaid is a vital resource for low-income individuals and families who require medical care but cannot afford it. The program covers a wide range of services, including breast reduction surgery, for those who meet the eligibility criteria. However, the process of getting approval for breast reduction surgery through Medicaid can be complex and time-consuming.
The length of time it takes for Medicaid to approve breast reduction surgery can vary depending on several factors, including the specific requirements of the state Medicaid program, the individual’s medical history and needs, and the availability of funding for the procedure. In general, the approval process for Medicaid coverage of breast reduction surgery can take anywhere from a few weeks to several months.
To qualify for Medicaid coverage of breast reduction surgery, individuals must meet certain criteria, such as having a medical need for the procedure due to physical discomfort or pain, and providing documentation from a healthcare provider supporting the necessity of the surgery. Additionally, some states may require individuals to undergo a psychological evaluation to assess the emotional distress caused by large breasts before approving coverage for the surgery.
Overall, while Medicaid can be a valuable resource for individuals in need of breast reduction surgery but cannot afford it, the approval process can be lengthy and complex. It is important for individuals considering this procedure to be patient and persistent in navigating the Medicaid system to access the care they need.

How Long Does It Take For Medicaid To Approve Breast Reduction
Before we dive into the approval process, let’s first understand how Medicaid coverage for breast reduction works. Medicaid coverage varies from state to state, so it’s important to check with your specific Medicaid program to determine the eligibility criteria and coverage details.
In general, Medicaid may cover breast reduction surgery if it is deemed medically necessary. This means that the surgery is not solely for cosmetic purposes but is required to alleviate physical symptoms such as back pain, neck pain, or skin irritation caused by large breasts. Medicaid will typically require documentation from a healthcare provider supporting the medical necessity of the procedure.
Factors Affecting Medicaid Approval Time
The time it takes for Medicaid to approve breast reduction surgery can vary depending on several factors. Here are some factors that may affect the approval time:
- Documentation: Providing thorough and accurate documentation from your healthcare provider is crucial for a smooth approval process. Make sure to include medical records, imaging results, and any other relevant information that supports the medical necessity of the procedure.
- Prior Authorization: Some Medicaid programs require prior authorization for certain procedures, including breast reduction surgery. This means that your healthcare provider will need to submit a request for approval before the surgery can take place. The time it takes for the prior authorization process can vary, so it’s important to start the process as early as possible.
- Review Process: Once all the necessary documentation and prior authorization requests are submitted, Medicaid will review the case to determine if the surgery meets their criteria for coverage. The review process can take time, especially if there is a high volume of requests or if additional information is needed.
Typical Timeline for Medicaid Approval
While the approval time can vary, it’s helpful to have a general idea of the timeline for Medicaid approval for breast reduction surgery. Here is a typical timeline:
- Consultation: Schedule a consultation with a healthcare provider who specializes in breast reduction surgery. During the consultation, they will assess your medical history, physical symptoms, and determine if you meet the criteria for the surgery.
- Documentation Gathering: Work with your healthcare provider to gather all the necessary documentation to support the medical necessity of the procedure. This may include medical records, imaging results, and letters of medical recommendation.
- Prior Authorization Submission: If required by your Medicaid program, your healthcare provider will submit a prior authorization request to Medicaid. This step may involve filling out forms, providing supporting documentation, and waiting for approval.
- Review Process: Medicaid will review the case and determine if the surgery meets their criteria for coverage. This process can take several weeks, depending on the volume of requests and the complexity of the case.
- Approval or Denial: Once the review process is complete, you will receive a notification from Medicaid regarding the approval or denial of your breast reduction surgery. If approved, you can proceed with scheduling the surgery. If denied, you may have the option to appeal the decision.
Tips for a Smooth Approval Process
To increase the chances of a smooth approval process, consider the following tips:
- Research your Medicaid program: Familiarize yourself with the specific eligibility criteria and coverage details of your Medicaid program. This will help you understand what documentation is required and what steps you need to take.
- Choose an experienced healthcare provider: Select a healthcare provider who has experience working with Medicaid and has a track record of successful approvals for breast reduction surgery. They will be familiar with the documentation requirements and can guide you through the process.
- Start early: Begin the approval process as early as possible to allow for any potential delays or additional documentation requests.
- Follow up: Stay in touch with your healthcare provider and Medicaid to ensure that all necessary documentation has been submitted and to check on the status of your case.
Medicaid Breast Reduction Requirements
Breast reduction surgery, or reduction mammaplasty, is a type of plastic surgery that involves the removal of excessive amounts of breast tissue, skin, and fat, resulting in the reduction of breast size.
Breast reduction surgery may help relieve some health issues, such as chronic back and neck pain, rashes and skin chafing underneath the breasts. If the size of an individual’s breasts are keeping someone from performing routine physical activities, it can impact someone’s physical and mental health. Every year in the United States, well over 100,000 breast reduction surgeries are performed. Some women choose to have the surgery for cosmetic reasons, but most women opt for breast reduction to relieve their health issues.
Out-of-pocket costs for breast reduction surgery without insurance coverage average around $6,000.00 in the United States. This amount varies greatly depending on the location, the cost of the facility, surgeon and anesthetist fees, tests required, prescriptions, as well as the length of stay and after-care. If your physician has suggested breast reduction surgery to relieve your related health issues, it is important to have all the details of whether your surgery is covered by Medicare or Medicaid.
Does Medicare Cover Breast Reduction Surgery?
Original Medicare benefits do not usually cover cosmetic or elective surgeries. Eligibility for Medicare coverage of breast reduction surgery requires that you have been experiencing symptoms for at least six months, and you must have previously tried other non-surgical means of medical intervention that have failed for symptom relief. If your physician certifies that the procedure is medically necessary, Medicare may help cover the costs of your surgery in a facility that accepts Medicare assignment.
Original Medicare Part A (Hospital Insurance) may help cover a surgery you have when you are formally admitted into a hospital as an inpatient. Because there are many variables involved with different surgeries and procedures, it is difficult to determine the exact final cost in advance.
Before admission to the hospital as an outpatient, you are responsible for paying the Medicare Part A deductible which, in 2019, is $1,364.00 for each benefit period. A Medicare benefits period begins on the day of your admission to the hospital and ends when you have not received inpatient care for 60 consecutive days.
From the first day of your inpatient care up to day 60, there is $0 coinsurance cost for each benefit period. From day 61-90, the charge in 2019 is $341.00 daily for each benefit period. After day 91, coinsurance is $682.00 for every lifetime reserve day after day 90 per benefit period. If you go beyond your lifetime reserve days, coinsurance is 100 percent of all costs.
People who are dual-eligibles receiving both Medicare and Medicaid services, Medicaid may pay for the deductible and coinsurance costs depending on which level of Medicaid they receive.
Does Medicaid Cover Breast Reduction Surgery?
More than 10 million people living in the United States get Medicare and Medicaid benefits at the same time. This means they are dual-eligibles because they are federally qualified for Medicare and meet their home state’s qualifications for Medicaid.
When beneficiaries have dual eligibility, first Medicare covers all expenses, then Medicaid pays the other costs and services remaining. These costs may include deductibles, copayments, and coinsurance costs. This coverage includes surgeries such as breast reduction.
Based on individual circumstances, qualification for either full dual eligible coverage, or partial dual eligible coverage is determined by the regulations of your home state. If you have full coverage, Medicaid pays for procedures and services that Medicare does not. If you have partial coverage, Medicaid covers the cost of Medicare premiums and other cost sharing expenses.
The majority of states in the United States use the federal Supplemental Security Income (SSI) income and asset guidelines to determine eligibility. To qualify for full dual eligible coverage, your income must be 300 percent of the Supplemental Security Income limit or less. In 2019, the Supplemental Security Income limit is $771.00 per month, 300 percent of that is $2323.00 per month.
States that apply Supplemental Security Income regulations, have a $2000.00 limit on countable assets per person. When both people in a marriage are receiving care, the limit is $3,000.00. These assets do not include the home you own and reside in.
Every state in the country sets regulations for resources and income allowances. You can find your state’s information online or at a local Medicaid services office.

Does Medicaid Cover Breast Reduction And Lift
Medicaid, the government health insurance program for low-income individuals, covers breast reduction surgery in specific cases where the unaffected breast lacks or has lost tissue due to a genetic condition. This coverage extends to situations where tissue loss in one breast is a result of an accident or cancer treatment. The coverage for breast reduction surgery in these circumstances is crucial for individuals who may experience physical discomfort or emotional distress due to asymmetry or other issues related to breast size.Individuals with a genetic condition that causes significant asymmetry in breast size may be eligible for Medicaid coverage for breast reduction surgery. Conditions such as Poland syndrome, which is characterized by underdevelopment or absence of chest muscles on one side of the body, can result in noticeable differences in breast size. In such cases, surgery to reduce the size of the unaffected breast can help improve symmetry and alleviate physical and emotional challenges associated with the condition.Similarly, individuals who have undergone cancer treatment that resulted in tissue loss in one breast may qualify for Medicaid coverage for breast reduction surgery. Breast cancer treatments such as mastectomy, which involves the removal of breast tissue, can lead to significant changes in breast size and shape. Breast reduction surgery on the unaffected breast can help restore balance and improve overall quality of life for individuals who have experienced such changes due to cancer treatment.It is important to note that Medicaid coverage for breast reduction surgery is typically subject to specific criteria and guidelines set forth by the program. Individuals seeking coverage for this procedure should consult with their healthcare provider and Medicaid representatives to determine eligibility and navigate the approval process. Additionally, it is essential for individuals to understand the potential risks and benefits associated with breast reduction surgery, as well as alternative treatment options that may be available.
Criteria for Medicaid Coverage of Breast Reduction Surgery |
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Genetic condition causing significant breast asymmetry |
Tissue loss in one breast due to accident or cancer treatment |
Consultation with healthcare provider and Medicaid representatives |
Conclusion
Getting Medicaid approval for breast reduction surgery can take time, but it is possible with the right documentation and support. By understanding the Medicaid coverage criteria, gathering the necessary documentation, and following the recommended tips, you can navigate the approval process more smoothly. Schedule a consultation with Medical Health Authority today to learn more about the process and get started on your breast reduction journey!
Key Takeaways
- Medicaid may cover breast reduction surgery if it is deemed medically necessary.
- Factors such as documentation, prior authorization, and the review process can affect the approval time.
- The typical timeline for Medicaid approval includes consultation, documentation gathering, prior authorization submission, review process, and approval or denial.
- Researching your Medicaid program, choosing an experienced healthcare provider, starting early, and following up can help facilitate a smoother approval process.