Medical necessity is a Medicare requirement for breast reduction.
Individuals in medical need of breast-reduction surgery, yet who possess only Medicare insurance coverage, may face a daunting bureaucratic gauntlet in trying to secure coverage for this procedure. Additionally, some physicians are increasingly wary of providing these services to Medicare patients.
Identification
Individuals with exceptionally large, sagging breasts are considered to have a condition known as macromastia, a condition that often causes back, neck and shoulder pain. Other frequent discomforts and problems are furrowing along the shoulders due to pressure placed on bra straps, irritation and rash beneath the breasts, difficulty in exercising due to heavy breast weight and having one breast that is significantly larger than the other. Women who intend to breast-feed and those whose breasts are not yet fully developed are encouraged to delay breast reduction surgery.
Significance
Reduction mammaplasty is the precise medical term for breast-reduction surgery. "Fatty tissue in the breast, along with glandular tissue and excess skin, are removed," according to Dr. Stuart Linder, a Beverly Hills, California breast-reconstruction specialist. "By removing these elements, the breast can be pulled tighter, making them lighter, smaller and firmer." The procedure is normally performed under general anesthesia, requiring between two and four hours of operation time.
Medical Necessity
Medicare, technically speaking, will pay for medically necessary breast-reduction surgery due to the fact that it is considered a reconstructive, rather than cosmetic, surgery, but many factors will influence eligibility. The American Society of Plastic Surgeons reports that a physician will need to provide documentation of pain, functional limitations and other health problems suffered by a patient with exceptionally large breasts. Photos and volumes of evidence will typically be necessary to guarantee any Medicare coverage. Pre-certification of Medicare's payment for this procedure is important.
Physician Restrictions
Some physicians, frustrated by the minimal compensation provided by Medicare, refuse to provide breast-reduction surgery to those covered only by this government program. "Medicare pays so poorly for breast reduction that we can no longer offer this service to our Medicare patients," advises Dr. John Di Saia, an Orange County, California, plastic surgeon. Additional cuts to the fees paid by Medicare may force other surgeons to also abandon the program, according to a survey conducted by the American College of Surgeons (ACS). While 96 percent of respondents currently participate in Medicare, less than one-third of them will be able to remain as Medicare participating physicians, reports the ACS.
Cost
Total charges for breast reduction surgery vary widely, but typically range from $4,200 to $7,000, according to American Society of Plastic Surgeons. This price usually includes surgeon's fees, hospital or surgical facility cost, anesthesia fees, prescriptions for medication, post-surgery garments and medical tests. However, as with many medical procedures, the actual price may be dependent on the amount of work to be performed. "If your breasts are extremely oversized and additional work is needed to remove excess tissue and to reposition and reshape the nipple area, then the procedure will be more costly," states The Consumer Guide to Plastic Surgery.
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