Does Humana Pay for Breast Reduction Surgery?

Visit Humana-MedicareAdvantage.com

Humana Medicare Advantage plans (also called Medicare Part C) cover breast reduction surgery that is considered medically necessary.

In this review, we outline how and when a Humana Medicare plan covers breast reduction surgery, and we show you how you can compare Medicare Advantage plans from Humana to find a plan near you that covers breast reduction surgery and more.

When Does Humana Cover Breast Reduction Surgery with a Medicare Plan?

Humana Medicare Advantage plans – like all Medicare Advantage plans – are required by law to cover everything included under Original Medicare (Medicare Part A and Part B). And because Original Medicare covers breast reduction surgery when certain conditions are met, so too will a Humana Medicare Advantage plan. 

Medicare considers a breast reduction (reduction mammaplasty) medically necessary when the patient shows significant symptoms that interfere with normal daily activities for at least 6 months despite conservative management.

At least one of the following criteria must also be met:

1. A history of back and/or shoulder pain with affects activities of daily living
2. A history of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity
3. Signs and symptoms of intertriginous maceration or infection of the inframammary skin, refractory to dermatologic measures or shoulder grooving with skin irritation by a supportive garment

Medicare also gives considerable attention to the amount of breast tissue being removed in differentiating between a cosmetic or medically necessary breast reduction. At least a minimal amount of tissue must be removed for the procedure to be considered medically necessary. 

Humana Medicare Advantage plans are required to provide coverage of breast reduction surgery when medically necessary. However, a Medicare Advantage plan may have certain restrictions and conditions that are unique to the plan and may have coverage determinations that differ from those of Original Medicare.

You will also likely need to have the procedure performed by a participating provider to maximize your coverage. 

Contact Humana directly by calling the phone number on your Plan ID card or by logging into your MyHumana account to learn about the exact details of the breast reduction coverage associated with your plan. 

How Do Insurance Companies Like Humana Define “Medically Necessary?”

Large breasts can lead to pain in the back, neck and rib cage. It can also lead to poor posture, which in turn can cause additional pain. 

Each insurance company is different in how it defines what is and isn’t medically necessary. But it’s common for insurance companies to require a patient to have a documented history of treatment for their pain such as physical therapy, chiropractic treatment or an orthopedic consultation. The patient will also typically need to be referred to a surgeon or specialist by their doctor. 

Based on a patient’s treatment history and referrals, an insurance company like Humana will then determine if a breast reduction surgery is medically necessary to alleviate the pain and thus will qualify for coverage. 

Breast reduction surgery may also be considered medically necessary following a mastectomy for breast cancer. If one breast was reduced in size due to a single mastectomy, the other breast may qualify for a covered breast reduction. 

Again, each insurance company has its own way of determining if a breast reduction surgery is medically necessary and eligible for coverage. And within each company’s parameters will likely be a case-by-case determination of coverage. 

If you are enrolled in a Humana employer-based insurance plan, contact Humana directly to inquire about your breast reduction surgery benefits. 

How Much Does Breast Reduction Cost With Humana Medicare Advantage Plans?

The cost of a breast reduction surgery without insurance can be around $5,800 on average, which includes fees for anesthesia, tests and exams, medications, post-operation garments and hospital or surgery center costs. With a Humana Medicare Advantage plan, however, your out-of-pocket costs may vary.

Some plans may have a deductible for medical care that you must meet before your plan coverage kicks in. After that point, you will typically be responsible for the 20% Medicare coinsurance cost for covered breast reduction surgery, and your Humana Medicare Advantage plan would pay the other 80%.

Some plans may feature different deductible or coinsurance/copay costs, so be sure to check with a licensed insurance agent or with your plan carrier directly to find out how much your surgery may cost.

How Can I Enroll in a Humana Insurance Plan?

You can call to speak with a licensed insurance agent to discuss the Humana Medicare Advantage plans that are available where you live and how they cover breast reduction surgery. There may be additional plans available in your area that address your other health care needs and other aspects of women’s health, including certain prescription drugs and annual wellness visits.

You can also compare plans online to find a Humana Medicare plan that fits your needs.