What Does Medicare Cover for a Double Mastectomy?

What parts of Medicare cover mastectomy?

Medicare generally provides coverage for most cancer treatments. If you need a mastectomy to treat breast cancer, you will be covered under your Medicare benefits, with some out-of-pocket costs. Different parts of Medicare pay for different services based on what’s involved in your particular surgery.

Doctor’s visits and outpatient care

Medicare Part B is the part of Medicare that covers outpatient procedures, doctor’s visits, and medical services. This part of the program will cover any doctor’s visits related to your mastectomy and cancer care, as well as outpatient surgery.

Inpatient surgery and care

Medicare Part A is the part of Medicare that covers inpatient hospital services. This part of the program will pay for your mastectomy surgery and related inpatient care.

Reconstruction

Medicare Part A will cover surgically implanted prostheses after your mastectomy, if you choose to have reconstruction. Medicare Part B will cover external prostheses after your mastectomy, as well as the special post-surgery bras you’ll need.

If you have Medicare Part C, a Medicare Advantage plan, your coverage for parts A and B are the same. However, you may have additional prescription drug coverage and other added benefits, based on the specific plan you’ve chosen.

Medications

Medications given while you’re admitted as an inpatient are covered under Medicare Part A. Some oral chemotherapy medications are included under Part B when given in an outpatient setting.

If other medications are prescribed in relation to your mastectomy, you’ll need to have a Medicare Part D plan or a Medicare Advantage plan with prescription coverage. Otherwise, you may have to pay out of pocket for these.

If you have a Medicare Part D plan, medications for nausea, pain, or other issues after surgery should be covered. The exact amounts covered and the costs of your Part D plan will depend on your plan provider and location.

Prophylactic mastectomy and genetic testing

Medicare’s coverage of elective mastectomies are more difficult to navigate than those for treating cancer. Coverage for a prophylactic (preventative) mastectomy is not guaranteed by Medicare. However, it might be covered under your state’s Medicaid program.

Surgery for cosmetic reasons is not covered by Medicare.

You might want a mastectomy if you’re at high risk of developing breast cancer due to a genetic mutation or family history. If Medicare denies coverage in this situation, you can ask your doctor to provide more information and written documentation to support your claim.

Genetic testing is not typically covered by Medicare, but tests for common gene mutations that lead to breast cancer – BRCA1 and BRCA2 – are an exception. Medicare will cover BRCA testing if you have a personal history of breast cancer and meet one or more of the following criteria:

• you were diagnosed with breast cancer before age 45, with or without family history
• you were diagnosed before age 50 or have two breast primary cancers and you have close blood relatives who have had a similar diagnosis
• you had two breast primary cancers when you were first diagnosed with breast cancer before age 50
• you have a breast cancer diagnosis at any age and have at least two close blood relatives with certain other cancers
• you have a close male relative who has been diagnosed with breast cancer
• you’ve had epithelial ovarian, fallopian tube, or primary peritoneal cancer
• you are in a high-risk ethnic group, such as being of Ashkenazi Jewish background, even if you have no other family history
• you have a close family member with a known BRCA1 or BRCA2 mutation

Genetic testing must be carried out by a provider and facility that accept Medicare. Studies have shown that prophylactic mastectomies can lower the risk of developing breast cancer by more than 90% in women who have the BRCA1 or BRCA2 gene mutation.

What are the coverage rules and details?

To make sure that Medicare will cover your mastectomy, you should take the following steps:

• Ask your doctor to provide a written order stating you have a medical reason for a mastectomy.
• Be sure wording in the order matches codes for the International Classification of Diseases (ICD) system.
• Check that your doctor and the medical facility where you plan to have surgery participate in Medicare.
• For a prophylactic mastectomy, have your doctor provide information to support a high level of risk and medical necessity.

Medicare is required to cover both internally implanted breast prostheses, as well as external prostheses. These include surgical implants, exterior forms, and supportive garments like mastectomy bras and camisoles. To check on coverage for specific items, visit Medicare’s website.

What out-of-pocket costs can I expect?

For both Medicare parts A and B, you will be responsible for each of these deductibles, as well as coinsurance and copayment costs associated with your mastectomy. With Part B, you’ll pay 20% of the Medicare-approved amount for doctor’s visits and external prostheses, once you’ve met the Part B deductible.

If you have a Medicare supplement plan, also called Medigap, it can be used to help cover most of the out-of-pocket costs from your mastectomy.

Medicare Part A

In 2020, there are a number of out-of-pocket costs that might be associated with Medicare Part A, depending on how long you need care.

You will pay a deductible of $1,408 for each benefit period. A benefit period is tied to a hospitalization so you should meet your deductible from the mastectomy surgery alone. There is no limit to the number of benefit periods you are allowed each year or in your lifetime. Your share of out-of-pocket costs rises as you extend your benefit period.

Here’s the breakdown of costs to expect during a single benefit period:

• First 60 days. There are no additional out-of-pocket costs once the deductible is met.
• Days 61 to 90. You will pay $352 per day in out-of-pocket costs.
• Day 91 and beyond. The daily coinsurance cost rises to $704 per day for up to 60 days during your lifetime.
• After lifetime reserve runs out. You will have to pay 100% of these costs.

Medicare Part B

For Part B, you will pay a monthly premium based on your income, as well as out-of-pocket costs. The following list is an overview of costs with Medicare Part B:

• In 2020, the annual deductible for Medicare is $198.
• After the deductible is met, you will pay 20% of the Medicare-approved cost of covered items and services.
• There is no annual out-of-pocket maximum for Medicare Part B.

Medicare Part C

For Part C, your costs will depend on the plan you choose. Medicare Part C is a private insurance plan that combines all the aspects of Medicare parts A and B, and sometimes prescription drug coverage as well.

For all Medicare Part C plans, the annual out-of-pocket limit is $6,700. Your monthly premium, deductible, copayments, and coinsurance all count toward this out-of-pocket maximum.

Medicare Part D

Medicare Part D is the prescription drug plan under Medicare. Costs for this plan also depend on the plan and provider you choose, as well as your location.

While Medicare sets guidance for private insurers that offer these products, pricing and offerings can vary. You can expect to pay a monthly premium, an annual deductible, and copayments for prescription medications based on each plan’s drug tier system.

The maximum annual deductible for Part D plans in 2020 is $435. Copayments vary based on how much you spend in a year. There is also a coverage gap that can affect the amount you pay for your prescriptions. Eventually, you will reach the catastrophic coverage threshold. Once you do, you will only pay minimal costs for your prescriptions for the rest of the year.

More information on breast cancer and mastectomy

There are several kinds of breast cancer, and it can affect both men and women. Here are some recent statistics on the prevalence of breast cancer:

• About 12% (or 1 in 8) of women in the U.S. will develop invasive breast cancer during their lives.
• Roughly 1 in 883 men in the U.S. will develop invasive breast cancer in their lifetime.
• Breast cancer is the most common cancer in women in the U.S., next to skin cancer, making up about 30% of new cancer diagnoses.
• About 15% of women who develop breast cancer have a family member who was also diagnosed with the condition.
• Another 5 to 10% of breast cancer cases are linked to BRCA1 and BRCA2 genetic mutations.
• About 85% of breast cancers occur in women who have no family history or inherited mutations.

Mastectomy rates have increased in the United States from 12% in 1998 to 36% in 2011 while cancer rates have remained fairly stable. Improved surveillance and treatment options have been credited for an improvement in cancer rates.

Staging

How your cancer is treated may depend on your type of cancer. Surgery is usually the first step in breast cancer management and can be helpful in staging (identifying the size and spread of breast cancer).

Staging is a big factor in deciding the best surgical and follow-up treatment for breast cancer. During initial biopsies and microscopic studies, a doctor can determine if your cancer is invasive or non-invasive. Invasive cancers usually require surgery, but only some noninvasive breast cancers need surgery.

If you have a type of breast cancer that requires surgery, the first step is tumor removal. Next, you might receive systemic treatments and undergo any additional surgeries.

Surgical options

There are two main types of surgery to treat breast cancer:

1. Mastectomy, which is the removal of the entire breast
2. Breast-conserving surgery, or a lumpectomy, which removes only the cancerous area of the breast plus a small amount of tissue around it

Breast-conserving therapy (BCT) usually requires radiation treatment as well. Most women with early stage breast cancer can pursue BCT rather than a full mastectomy.

A mastectomy may be required because of cancer stage, breast or tumor size or shape, personal preference, or as a preventive measure if you are at high risk due to a genetic mutation. There are several different types of mastectomies, including:

• Simple mastectomy. The entire breast is removed but the axillary lymph nodes are left in place. A biopsy of the lymph node is performed to make sure the cancer has not spread.
• Skin-sparing mastectomy. All of the breast tissue is removed, but the skin over the breast area is left intact. This method is usually done when immediate reconstructive surgery is performed.
• Nipple-sparing and areola-sparing mastectomies. Similar to skin-sparing mastectomies, your doctor may be able to preserve the nipple and/or areola. This is typically done at the same time as reconstructive surgery.
• Modified radical mastectomy. All of the breast tissue and the axillary lymph nodes are removed.
• Radical mastectomy. Breast tissue, axillary lymph nodes, and underlying muscles in the chest wall are removed. This is the most extensive type of mastectomy.
• Contralateral prophylactic mastectomy. A healthy breast is removed at the same time as a the cancerous breast to reduce the chance of future cancer development.
• Prophylactic double mastectomy. Both breasts are removed due to a high risk of cancer, often from a genetic mutation.

What to expect before and after surgery

A mastectomy is a major surgery that will require preparation, at least several days in the hospital, and an extensive recovery process. The type of cancer you have may also require systemic treatments or radiation therapy. Even prophylactic surgeries have long-term impact, both physically and emotionally.

Find a community that cares

It can be helpful to connect with people who understand exactly what you’re going through. Breast Cancer Healthline is a free app that provides support through one-on-one conversations and live group discussions with others living with breast cancer. The app is available for download on iPhone or Android devices.

The takeaway

• When it comes to having a mastectomy for cancer treatment or other medical needs, Medicare will cover most of the costs associated with the procedure.
• You will be responsible for your share of the costs under normal Medicare rules for Medicare parts A, B, C, and D.
• Coverage for prophylactic mastectomy is not guaranteed. Work with your doctor to make sure documentation emphasizes your level of risk.
• Mastectomies for cosmetic reasons will not be covered if there is no medical need.