Does Kaiser Permanente Cover a Breast Reduction?
- Kaiser Permanente Medicare Advantage plans may cover breast reduction surgery under certain circumstances. Explore medical necessity and other plan requirements for this procedure.
Some Kaiser Permanente Medicare Advantage (Medicare Part C) health insurance plans can cover breast reduction surgery if your healthcare provider says the procedure is medically necessary and if the surgery meets requirements for Original Medicare (Medicare Part A and Part B) coverage.
When Does Kaiser Cover Breast Reduction Surgery?
Kaiser Permanente Medicare Advantage plans may help cover breast reduction procedures when unusually large breast size leads to medical issues. However, coverage typically excludes breast reductions done solely for cosmetic reasons.
How Much Does Kaiser Pay for Breast Reduction Surgery?
Coverage depends on your exact plan and its cost-sharing provisions. Different Medicare Advantage plans can feature different deductibles or copay amounts, so be sure to compare plans that are available in your ZIP code.
When Is Breast Reduction Medically Necessary?
As discussed, your healthcare provider must document that a breast reduction is medically necessary for a Kaiser Permanente Medicare Advantage plan to provide coverage. Your doctor may diagnose macromastia, or abnormally large breasts, if their size and weight cause:
- Chronic back, neck and/or shoulder pain
- Permanent marks in the shoulders because of bra straps
- Rashes under the breasts that do not heal or go away and come back
Kaiser Permanente plans may also cover breast reduction related to reconstruction after mastectomy.
How Can I Show Medical Necessity for Breast Reduction?
Before you can receive coverage for breast reduction surgery through a Kaiser Permanente Medicare Advantage plan, you have to apply for authorization. Some documents the insurance company may require to prove medical necessity include:
- Medical records that detail your height, weight and breast size
- Photos of your breasts
- A letter from your healthcare provider explaining the symptoms that arise because of your breast size
- Notes about how your breast size affects your life, such as limiting your ability to engage in physical activity
Generally, you must have proof from a doctor that you have medical symptoms arising from your breast size. You also have to show that you have tried other treatments, such as diet and exercise, that have not been successful.
What May Disqualify You for Breast Reduction Coverage?
Kaiser Permanented may decline to cover your breast reduction if the company finds the procedure does not meet its medical necessity requirements. You may also be disqualified if you cannot safely have the surgery.
For example, you might be asked to lose weight, treat chronic health conditions or quit smoking before a Kaiser Permanente Medicarte Advantage plan will cover your breast reduction.
Helpadvisor.com is owned and operated by Tranzact, the parent company of TZ Insurance Solutions LLC, which is the owner/operator of MedicareAdvantage.com and other websites mentioned on HelpAdvisor and which has a financial relationship with some of the carriers listed on HelpAdvisor.
