Prescriber And Provider Requirements
Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversals of claims.
NIHB recognized prescribers/recommenders include:
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Can Breast Reduction Be Covered By Medicaid
The best way to determine if your breast reduction can be covered by Medicaid is to call your states Medicaid hotline.
Medicaid is a government-funded insurance program for low-income Americans. If you qualify for Medicaid, your doctor will perform your surgery at no cost to you.
However, there are certain criteria that must be met in order for breast reduction surgery to qualify as medically necessary.
In order to qualify for Medicaid, it must be determined that the procedure is medically necessary and that the benefits outweigh any risks or side effects associated with the procedure.
To meet these criteria and get coverage through Medicaid, your doctor will need to document that:
-You have clinically significant breast tissue that interferes with your daily life
-You had symptoms of this condition before age 18
-Your symptoms began within six months of pregnancy or childbirth
How Do I Qualify For The Medicare Rebate
In order to qualify for a rebate from Medicare, you must meet certain Medicare criteria.
Your eligibility to claim your breast lift with Medicare will depend on the degree of breast ptosis as well the age of your youngest child.
The below MBS Codes may be applicable for Breast Lift Surgery
- 45558 Breast Lift Mastopexy Bilateral
- 45556 Breast Lift Mastopexy Unilateral payable only once per occasion
Full MBS Item Number breakdown/Description
- 45558 Breast ptosis, correction by mastopexy of , if: at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour and if the patient has been pregnant-the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient and photographic evidence , with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes Applicable only once per lifetime
- 45556 Breast ptosis, correction of , in the context of breast cancer or developmental abnormality, if photographic evidence and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes Applicable only once per occasion on which the service is provided
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How Much Is A Breast Reduction With Medicaid
If youre on Medicaid, a breast reduction can be one of the best investments you make. Its not just about the moneyits about your health and your overall quality of life.
If youre thinking about getting a breast reduction, here are some things to consider:
Youll be able to sleep better. You wont have to toss and turn at night because your breasts are pressing against your chest, causing discomfort
Youll be able to exercise more comfortably. You wont feel like your bra is constantly slipping off or digging into your skin when youre running or doing other physical activities
Your clothing will fit better. Your clothes will hang better on your body after surgery because therell be less bulk in the chest area
Breast reduction surgery can be a life-changing experience. For many women, having large breasts is a source of pain and discomfort, as well as an embarrassing problem that affects their self-confidence. They may have difficulty finding clothes that fit or feel comfortable due to the size of their breasts they may be constantly tugging at their bras or struggling to find a bra that fits properly. They may have trouble sleeping on their backs because their breasts are too large and heavy, which can lead to back pain.
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Can Your Breast Sag After Breast Reduction
There is no expiration date on the results of breast reduction surgery, but as part of a living, breathing body, breasts change over time. Because your breasts are lighter than they were before surgery, they will sag far less than they would have, but age and the effects of gravity canât be avoided completely.
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Does Medicare Pay For A Breast Reduction
Medicare is not an option in the case of cosmetic surgery. If medically required, Medicare will pay for breast reductions. Reconstruction following a mastectomy or a reduction to relieve discomfort are examples of cases where it is medically necessary. In some cases, Medicare may provide you with coverage in place of Medicare Advantage.
How Do You Qualify For Medicare Rebate For Breast Reduction Surgery Mbs Codes
These MBS Codes may be applicable for Breast Reduction Surgery:
45523 Reduction mammaplasty with surgical repositioning of the nipple:
for patients with macromastia and experiencing pain in the neck or shoulder region and
not with insertion of any prosthesis
45520 Reduction mammaplasty with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast
45522 Reduction mammaplasty without surgical repositioning of the nipple:
excluding the treatment of gynecomastia and
not with insertion of any prosthesis
What these terms mean:
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Can I Get Michigan Medicaid To Accept A Breast Reduction
I live in Michigan, I am a 22 mother of rwo kids and ny breasts make me miserable. I am 52 and I am finally getting into fitness, but my breasts make it close to impossible. I cant run like I want, the sports bra rubs against my collar bone and rubs my skin off. My back always hurts, lately it has been harder to breathe. This isnt how my body should be. Could I get Medicaid to accept a breast reduction? Its my only option left! To finally feel comfortable with my own body!
What Is Breast Reduction Surgery
Breast reduction surgery is another name for a procedure called reduction mammoplasty. During the procedure, surgeons remove excess fat and tissue from the breasts to reduce their size and weight. Breast reduction surgery can help relieve back pain, chafing or rash under the breasts and neck strain. It may also alleviate any psychological symptoms associated with having large breasts.
Although many women choose to have breast reduction surgery to relieve troublesome health symptoms, the surgery is sometimes performed for cosmetic purposes.
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Changes To Five Types Of Surgeries
CMS has raised concerns that Medicare is paying for cosmetic procedures at an increasing rate, more than would be expected based on an increasing number of Medicare beneficiaries or on advances in medical treatments.
It is presumed that medical providers may be claiming procedures that are medically necessary when they may not be. To decrease Medicare costs and to preserve the Medicare Trust Fund, they have specifically targeted five categories of outpatient procedures.
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Services Included In The Price
The following services must be included in the price of the item to be considered for coverage:
- product or parts ordering and delivery from manufacturer/supplier to provider
- casting or scanning of the body part to design the prosthesis
- fabrication and aligning components of the prosthesis
- evaluation, any adjustments to optimize function or fit
- client education of prosthesis use and final dispensing of prosthesis
- follow-up visit, as per professional association guidelines
How To Reach Prior Authorization Staff With An Authorization Request
When you need care, always start with a call to your PCP. Some covered services may need prior approval. They may need review by Sunshine Health before services are given. This includes services or visits to an out-of-network provider. Hospital stays, transplants, home health services, some surgeries, medical equipment and some medicines require prior approval. Your doctor can tell you if a service needs a prior approval. The list of these services can be found below.
You can also call Member Services if you have questions. The number is 1-866-796-0530.
Some covered services require a prior authorization from Sunshine Health before the service is provided. The list of services that need a prior authorization can include an admission to the hospital after your emergency condition has improved, power wheelchairs, home health visits, MRI X-rays, hospice care, genetic testing, pain management or some outpatient surgery. That list is on our website at SunshineHealth.com. Your PCP or other doctor that is treating you can request an authorization from Sunshine Health. When your doctor requests an authorization, he or she must send information about your health condition and treatment. This may include copies of your medical record, results of tests, what medications you have tried, or what kind of support you need to take care of yourself at home. You can go to any participating Sunshine Health doctor for covered services.
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Surgeons Who Accept Medicaid For Top Surgery
Medicaid is a state-run health insurance program that provides payment for medical services for low-income citizens. The map below shows which states have have clarified that the state Medicaid program covers transition-related care.
Important Note: Even in states not listed here, transgender exclusions in Medicaid plans may violate the Affordable Care Act and other federal and state laws. National Center for Transgender Equality
If you live in California:This guide will help you understand the procedural steps to appeal a health care denial for health care plans that are managed by Medi-Cal.
If you live in New York:This guide will help you navigate getting Medicaid coverage for Top Surgery in New York.
Mastectomy For Male Gynecomastia
Mastectomy for gynecomastia is an operation to remove breast tissue in adult males. Male gynecomastia is caused by excessive growth of the male mammary glands.
Medicaid covers mastectomy for males if the following conditions are met:
1. If the adult recipient has a history of gynecomastia that continues for more than three months after pathological causes have been ruled out.
2. If the adolescent recipient has a history of gynecomastia that continues for more than six months after pathological causes have been ruled out.
3. If the excessive tissue is glandular and not fatty as established by a mammogram.
4. If the excess tissue growth is not caused by non-covered treatments, prescriptions, alcohol, or abuse of illegal drugs such as anabolic steroids, marijuana, etc.
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Will Medicare Help Fund Breast Reductions
Yes if you meet the criteria outlined below. The rebate itself is around $1000 but importantly, you must be entitled to the Medicare number to ensure that your private health insurance to kick in.
The Medicare item number to check with your health fund is 45523. Not all policies will cover this item, so you may consider a change to your cover or even fund.
It is important to demonstrate clinical need, including pain in the neck and/or shoulder region. While consulting with your GP, it is worth discussing these symptoms to ensure the clinical need is documented in your referral for surgery which makes it easier for me to determine your eligibility for the Medicare item number.
For more details on our fees and the criteria Medicare use to determine if you can have a rebate, you can visit our breast reduction page.
Will Medicare Cover Breast Reduction Surgery For Medical Reasons Mbs Criteria
If you have required documentation for breast reduction surgery and you meet the Medicare criteria, you can qualify for a rebate. It is important to note that the recent MBS changes included additional photographic proof, examination evidence, reporting documentation, and stricter patient criteria for Medicare rebates.
Your eligibility will essentially be based on the following Medicare criteria
for patients with macromastia and experiencing pain in the neck or shoulder region and
not with insertion of any prosthesis this means you cannot have an implant put in when having the reduction to be able to claim the rebate
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Can I Have A Breast Reduction Done In The Public System
- There is a limited NSW public training hospital budget for breast reductions and due to covid a very long waiting list for elective surgery. You will be unlikely to have a highly experienced and skilled plastic surgeon perform a public breast reduction surgery. Please call the NSW Government Surgery Access Line on 1800 053 456 for more info.
How Do You Qualify For Medicare Rebate For Breast Lift Surgery
To qualify for a rebate from Medicare you will need to meet certain Medicare criteria, for either a breast reduction and or breast lift surgery.
Your eligibility will depend on the age of your youngest child and/or your degree of breast ptosis .
These MBS Codes may be applicable for Breast Lift Surgery
- 45558 Breast Lift Mastopexy Bilateral
- 45556 Breast Lift Mastopexy Unilateral â payable only once per occasion
Full MBS Item Number Description
- 45558 Breast ptosis, correction by mastopexy of , if: at least two-thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour and if the patient has been pregnant-the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient and photographic evidence , with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes Applicable only once per lifetime
- 45556Breast ptosis, correction of , in the context of breast cancer or developmental abnormality, if photographic evidence and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes Applicable only once per occasion on which the service is provided
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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.
Breast Reduction Surgery Costs
The average cost of breast reduction surgery is about $6,000. This includes the fees for the surgeon, facility you get the procedure at and anesthesia.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
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Tips For Dealing With Your Health Fund
- If Medicare does not cover your surgery you will also lose any potential health fund rebates too.
- Health Funds will only provide coverage when there is a Medicare Number attached to your procedure.
- If your procedure has an MBS code, its imperative you check any health conditions or other eligibility requirements.
- Your level of cover at your health fund is critical many surgeries now require GOLD level Cover
- Find out the meaning of medically indicated and Statement of benefit.
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Answer: Getting Insurance To Possibly Cover Breast Reduction Surgery
With Michigan Medicaid or other types of insurance you need to follow a strict course of action.!. Write and ask the insurance for specific guidelines they seek or require.2. Get a supportive factual letter from your plastic surgeon.3. Make sure your PS is an ABPS-FACS surgeon.4. Get a supportive factual letter from your family doctor.5. Get a supportive factual letter from you orthopedic surgeon.6. Document neck pain and back pain and obtain xrays or CAT scans.7. Have excellent photos taken including photos of submammary skin irritation.8. Have Physical Therapy and orthopedic documentation of disability of back and of neck.9. Have 2 plastic surgeon opinions.10. Have photos of bra strap shoulder notching.11. Have documentation of your being the correct or at least reasonable weight. Photos help.12 Dermatologist reports of inframammary dermatitis from skin on skin rubbing.13. Have reports of work missed from neck and back disability.14. No one likely will have all of this information available, but please be assurred that the more information you have, the more likely you will be approved. Little information means little likelihood of approval. 15. Have the surgeon supply the operative codes and the nature of the operation he plans.16. Be persistent, be accurate, and be honest. Let your breasts speak for themselves.My Very Best, Dr C
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