Does medicare cover breast reconstruction after lumpectomy

Medicare Mastectomy Coverage

Medicare covers most cancer treatments, including a mastectomy to treat breast cancer.

A mastectomy is a type of surgery that removes all breast tissue from a breast. A lumpectomy is a similar procedure that removes only the cancerous area of the breast and a small amount of tissue around it.

Both surgeries are covered by Medicare, but how much you pay out-of-pocket depends on several factors, including where the surgery takes place.

Reconstruction surgery is also covered by Medicare.

You may require post-mastectomy products and supplies after surgery. Medicare covers some, but not all, of these products.

Does Medicare Cover Double Mastectomy?

There are several types of mastectomies. Medicare covers them all so long as the procedure is considered medically necessary.

Types of Mastectomy Surgeries

Total (Simple) Mastectomy

Double (Bilateral) Mastectomy

Skin-Sparing Mastectomy

Nipple-Sparing Mastectomy

Radical Mastectomy

Make sure your doctor and the medical facility where you plan to have surgery participate in Medicare.

If you’re enrolled in a Medicare Advantage plan, you may be restricted to doctors and health care facilities within your plan’s provider network. Medicare Advantage beneficiaries will need prior authorization for the surgery.

Medicare Part A Coverage for Mastectomy

Medicare Part A covers inpatient hospital services. If you undergo a mastectomy as a hospital inpatient, you are covered by Part A.

Part A includes a $1,600 deductible in 2023 for each benefit period. You will also be responsible for 20% of doctor’s fees inside the hospital.

Medicare considers you a hospital inpatient covered by Part A when you are formally admitted to the hospital with a doctor’s order.

Medicare Part B Coverage for Mastectomy

Medicare Part B will cover your mastectomy if it takes place on an outpatient basis.

You will typically owe 20% of the Medicare-approved amount for:

• Same-day outpatient surgery
• Doctor and other health care provider's services
• Lab tests billed by the hospital
• X-rays and other radiology services billed by the hospital
• Medical supplies
• Anesthesia services
• Certain drugs administered in these settings, such as drugs given through an IV

Part B also covers durable medical equipment and supplies you may need after surgery, such as mastectomy bras and breast prostheses. You will owe 20% of the cost for these items as well.

Research shows that many mastectomy procedures are shifting to an outpatient setting.

In 2003, about 22% of mastectomies across 17 states were performed in a hospital outpatient setting.

By 2012, that number increased to 42%t, according to a study from the federal Agency for Healthcare Research and Quality.

Between October 2017 and August 2019, 64% of mastectomies took place on an outpatient basis, according to a 2021 research paper by the American College of Surgeons.

Medications

Following surgery, you will likely receive prescriptions for pain medication and possibly an antibiotic.

You may receive prescription drug coverage through a standalone Medicare Part D plan or through a Medicare Advantage plan with prescription drug coverage.

Copayments for medications are based on each plan’s drug tier formulary. Check with your plan provider if you have questions about cost.

Breast Reconstruction Surgery

Medicare covers breast reconstruction surgery following the removal of a breast.

Breast reconstruction can take place at the same time as your mastectomy or during a second operation later. More than one surgery is often required.

The Women’s Health and Cancer Rights Act of 1998 provides protection to patients who opt for breast reconstruction following a mastectomy.

Under the law, coverage must be provided for:

• All stages of breast reconstruction of the breast where the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Treatment of physical complications from the mastectomy, including lymphedema

How much you pay for reconstructive surgery depends on where the surgery takes place.

Part A covers reconstruction surgery if it takes place at an inpatient hospital. You Part A deductible applies.

If the surgery takes place in an outpatient setting, it is covered by Part B. As with the mastectomy surgery, you will owe 20% of all costs for the surgery, along with 20% for doctor services and any separately billed items.

You may owe less for your reconstructive surgery if you have supplement insurance, such as Medicaid or a Medigap policy.

What Do I Need Post-Mastectomy?

There are several products you may want or need following your mastectomy. Not all items are covered by Medicare.

Post-Mastectomy Products Covered by Medicare

• Silicone breast prostheses (also called breast forms)
• Non-silicone breast prostheses
• Mastectomy bras
• Post-surgical soft form camisoles

Medicare likely won’t cover other items, such as mastectomy pillows, mastectomy blouses or swimsuits.

Manufacturers make a wide selection of types, shapes, sizes and colors for post-mastectomy products.

Check with the retailer to see if they accept Medicare.

External Breast Prosthesis

A breast prosthesis, or breast form, is an artificial breast used after a mastectomy. A prosthesis can be worn against the skin, inside the pocket of a mastectomy bra or attached to the chest wall.

Medicare will cover one breast prosthesis per side for the life of the prosthesis.

The useful life for silicone breast prostheses is two years, while the useful life for fabric, foam or fiber filled breast prostheses is six months.

You can order a new external breast prosthesis sooner if your original prosthesis is lost or damaged.

Currently, Medicare does not cover custom breast prostheses.

A new external breast prosthesis of a different type is covered only if a change in your medical condition makes it necessary to use a different item.

Breast prostheses are covered under Medicare Part B. You will owe 20% of the cost, and Medicare pays the other 80%.

Mastectomy Bras and Camisoles

Both mastectomy bras and camisoles are covered by Medicare.

Mastectomy bras resemble regular bras but include inside spandex stretch pockets to hold and keep your breast prosthesis in place.

Soft form camisoles include a removable breast form that fits into the camisole garment. A post-surgical camisole is often worn immediately following a mastectomy or reconstruction breast surgery.

You can purchase mastectomy bras and camisoles online, at specialty shops or at mastectomy boutiques.

Some retailers have customer service representatives who can contact Medicare directly and file a claim on your behalf.

Did You Know?

Your physician, oncology nurse, local American Cancer Society Reach for Recovery program or other breast cancer organization can recommend local specialty shops and boutiques that carry prosthetic devices and garments.

You must get a prescription or written order from your doctor before Medicare will cover these items.

Medicare doesn’t specify a limit on the quantity of bras or camisoles it will cover. Instead, your doctor will determine what is reasonable and necessary on a case-by-case basis.

Mastectomy bras and camisoles are covered under Medicare Part B. You will owe 20% of the cost for each item.

Does Medicare Cover Genetic Testing for Breast Cancer?

Medicare covers genetic testing for people diagnosed with breast cancer who meet certain criteria.

Several variants of breast cancer exist, and some variants are inherited. The most common cause of hereditary breast cancer is an inherited mutation in the BRCA1 or BRCA2 gene.

In 2020, the U.S. Centers for Medicare & Medicaid Services began covering next generation sequencing, or NGS tests. This multigene panel can detect several types of genetic alterations at the same time.

Genetic testing can help your doctor identify more tailored treatment options.

To qualify for NGS testing coverage under Medicare, you must have:

• Breast or ovarian cancer
• A clinical indication for inherited testing for hereditary breast or ovarian cancer
• A risk factor for inherited breast or ovarian cancer
• Not been previously tested using NGS for the same cancer and genetic content

About 5% to 10% of breast cancer cases are thought to be hereditary, according to the American Cancer Society.

Medicare Guidelines for Prophylactic Mastectomy

Original Medicare generally doesn’t cover prophylactic, or preventative, mastectomies.

Some patients with a high risk for inherited breast cancer may elect to undergo this procedure because it can greatly reduce their chances of developing breast cancer.

Did You Know?

For women with the BRCA1 or BRCA2 gene mutation, prophylactic mastectomy surgery reduces the risk of developing breast cancer by 90% to 95%

Some Medicare Advantage plans may cover prophylactic mastectomies.

For example, Paramount Medicare Advantage HMO and PPO plans may cover this surgery if you meet certain criteria and the procedure is approved by your doctor. Paramount plans are available only in Ohio and cover about 237,000 members.

If you have a Medicare Advantage plan, check with your plan provider to see if preventative mastectomies are covered.

Choosing to undergo a prophylactic mastectomy is a major decision. Experts recommend working with a team of health professionals — including a genetic counselor — to get a complete evaluation of your risk and explore all your options.

Out-of-Pocket Costs for Mastectomy

Without insurance, estimates for mastectomies range between $13,000 and $21,177.

The American Society of Plastic Surgeons does not report average surgeon’s fees for breast reconstruction following a mastectomy. Some estimates put the average cost of reconstruction between $5,000 to $8,000.

How much you pay for your mastectomy with Medicare depends on many factors, including:

• Where the surgery takes place
• The type of surgery performed
• Whether the surgeon, doctor or hospital accepts Medicare
• If you have any supplement insurance, such as Medicaid or a Medigap policy

For example, if you opt to undergo a mastectomy as an outpatient, your procedure will be covered by Medicare Part B.

Without supplement insurance, you will owe 20% of the outpatient surgery cost, along with 20% for any doctor fees, hospital facility fees, anesthesia fees and medical tests.

According to Medicare.gov, the 20% copayment for a single outpatient service can’t exceed the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.

In contrast, if you undergo a mastectomy as a hospital inpatient, the procedure is covered by Medicare Part A.

You would need to meet the current $1,600 Part A deductible along with 20% of doctor’s fees. After that, all hospital costs are covered for up to 60 days.

It’s important to remember that if you require other unexpected services, your out-of-pocket costs may be higher.

Unfortunately, the financial burden of medical costs can create real problems for cancer patients.

According to a 2019 research study published in the Journal of Oncology Practice, a third of participants reported higher-than-expected costs for their breast cancer care.

The financial burden was most significant among women who underwent a double mastectomy — the most intensive surgery option.

Women with annual household incomes of $45,000 or less reported that their surgical choice was influenced more by cost than by the physical effects of different types of surgery.

Despite financial concerns, just 22% of patients in the study said they discussed the cost of care with their medical team prior to surgery.

It can be difficult to calculate the exact costs of a surgery in advance because your doctor can’t predict the extent of the services you’ll need. For example, if you experience complications during surgery, your costs could be higher than someone without complications.

To minimize surprises, experts recommend talking about the price of different treatment options early and often with your medical team.

Mastectomy Statistics

More than 100,000 women in the United States undergo some form of mastectomy each year, according to Brigham and Women’s Hospital.

Less than half of all women who required a mastectomy were offered breast reconstruction surgery in 2017, according to the American Society of Plastic Surgeons. Fewer than 20% elected to undergo immediate reconstruction.

Most women with small unilateral breast cancer are candidates for breast conserving surgery, yet one-third elect to undergo a mastectomy, according to the authors of a recent study published in the Journal of Surgical Research, who recommended “increasing patient-facing education pertaining to the risks associated with CPM” to discourage unnecessary surgery.

Breast cancer is the second most common cancer in American women after skin cancers. It’s estimated that 1 in 8 women will develop the disease during their lifetime.

Since 2007, breast cancer death rates among women over age 50 have continued to decrease, according to the American Cancer Society.

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