Does Medicare Cover Mastectomy?
- Does Medicare cover mastectomy? If it's medically necessary, Medicare covers some of the cost. Learn more about Medicare mastectomy coverage and what's covered.
"Does Medicare cover mastectomy?" It's a common question, especially since a mastectomy with reconstruction costs an average of $22,481. Your Medicare plan may cover a mastectomy if your doctor determines it's medically necessary to treat breast cancer. If you have a gene mutation that puts you at a high risk of developing breast cancer, Medicare may not cover a prophylactic (preventive) mastectomy unless your doctor submits a written explanation of why the procedure is necessary. Even if your doctor submits such an explanation, there's no guarantee Medicare will cover the surgery.
Does Medicare Cover Mastectomy for Breast Cancer?
"Does Medicare cover mastectomy?" is a question many people ask once they've been diagnosed with breast cancer and need to know if Medicare will cover the cost of surgery to treat it. Medicare coverage depends on the type of treatment you receive and where you receive it. If you have a mastectomy, Medicare Part A may pay for the surgical procedure and any post-surgery care you receive in the hospital. Medicare Part A covers things like in-hospital meals, nursing care, medications and medical supplies. If you decide to have surgically implanted prostheses, Medicare Part A may also cover the cost of the procedure.
Medicare Part B covers medically necessary services you receive on an outpatient basis. After your mastectomy, you may need to visit the doctor to have a drain removed or have a doctor to check the incision and make sure it's healing properly. For each outpatient service you receive, you'll have to pay a copay or coinsurance, as Medicare doesn't cover 100% of the approved amount. If you decide to use external prostheses instead of having surgically implanted prostheses, Medicare Part B may pay for them. Your Part B benefits may also cover mastectomy bras and camisoles designed to be used after mastectomy surgery.
Does Medicare Cover Mastectomy Medications?
Medicare Part A covers the medications you receive while you're in the hospital. For example, if you need intravenous pain medication after your mastectomy, that falls under your Part A benefits. Medicare Part B pays for some medications administered in a doctor's office. One example is chemotherapy delivered via an infusion. If you need chemotherapy after your mastectomy, it would be covered by your Part B benefits.
Original Medicare doesn't cover prescriptions that you administer yourself, but if you have Medicare Part D, you may be able to get coverage for your prescription medications. Part D is a supplemental plan that you purchase from an insurance company. The level of coverage available for post-mastectomy and other breast cancer medications depends on the terms of your plan.
Medicare Advantage (Medicare Part C) is considered an all-in-one plan because it bundles the benefits of Original Medicare with extra services. Many Medicare Advantage Plans come with prescription coverage, which means you may be able to use Medicare Advantage to pay for post-mastectomy medications.
Does Medicare Cover Prophylactic Mastectomy?
Some people with a heightened risk of breast cancer decide to have a prophylactic mastectomy to reduce their risk of developing the disease. Medicare may cover genetic testing to determine your breast cancer risk if you've been diagnosed with breast cancer and meet one of the following criteria:
- One of your close family members has a mutation in the BRCA1 or BRCA2 gene.
- Your breast cancer diagnosis occurred before you turned 45.
- Your ethnic background puts you at an increased risk of developing breast cancer.
- You were diagnosed with breast cancer at any age and have two close relatives with certain types of cancer.
- You've had one of the following types of cancer: fallopian tube, ovarian or primary peritoneal.
- You received a breast cancer diagnosis before the age of 50 or have two primary breast cancers and have close relatives with similar diagnoses.
- You received a diagnosis of two primary breast cancers before the age of 50.
- One of your close male relatives has received a breast cancer diagnosis.
If genetic testing reveals that you have a gene mutation that puts you at an increased risk of developing breast cancer, your doctor may recommend a prophylactic mastectomy. There's no guarantee Medicare will cover a prophylactic procedure, but you can increase your chances of approval by doing the following:
- Ask your doctor to provide a written explanation of why the prophylactic mastectomy is medically necessary.
- Make sure that your preferred hospital and surgeon participate in Medicare.
- Ask your doctor to write an order using the correct codes from the International Classification of Diseases.
Out-of-Pocket Mastectomy Costs
Even if the answer to "Does Medicare cover mastectomy?" is yes, that doesn't mean you won't have any out-of-pocket costs. If you use Medicare Part A to cover inpatient services, you'll have to pay your Medicare Part A deductible. Any services covered by Part B are usually covered at 80% of the approved amount, leaving you to pay the remaining 20%. One way to reduce your out-of-pocket expenses is to purchase Medicare Supplement Insurance, a supplemental plan that may cover Part B deductibles, copays and coinsurance.