For a mastectomy, Medicare Part A should cover your inpatient hospital costs, while Medicare Part B covers any other related outpatient services.
While mastectomy is one of the main ways to treat breast cancer, not everyone who undergoes this surgery has a cancer diagnosis. There are several types of mastectomies, including single mastectomies, where one breast is removed, and double mastectomies, where both breasts are removed.
Generally, Medicare covers most of the treatments needed after you receive a cancer diagnosis, including a mastectomy. However, some mastectomies do not qualify for Medicare coverage if they’re not deemed medically necessary for the situation.
Read on to learn more about when Medicare will cover a mastectomy and when it won’t.
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.
Doctors’ visits and outpatient care
Medicare Part B is the part of Medicare that covers outpatient procedures, doctors’ visits, and medical services. This part of the program covers any doctors’ 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 pays for your mastectomy surgery and related inpatient care.
Reconstruction
Medicare Part A covers surgically implanted prostheses after your mastectomy if you choose to have reconstruction. Medicare Part B covers external prostheses after your mastectomy as well as special postsurgery bras you may need.
If you have Medicare Part C, also known as 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, it typically covers medications for nausea, pain, or other issues after surgery. The exact amounts covered and the costs of your Part D plan depend on your plan provider and location.
Prophylactic mastectomy and genetic testing
Medicare’s coverage of elective mastectomies is more difficult to navigate than those for treating cancer. Coverage for a prophylactic (preventive) 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 the common gene mutations BRCA1 and BRCA2 that lead to breast cancer are an exception.
Medicare covers BRCA testing if you have a personal history of breast cancer and meet one or more of the following criteria:
- you received your breast cancer diagnosis before age 45, with or without family history
- you received your breast cancer diagnosis before age 50 or have two breast primary cancers, with at least one close blood relative with a similar diagnosis
- you had two breast primary cancers when you first got your breast cancer diagnosis 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 received a breast cancer diagnosis
- you’ve had epithelial ovarian, fallopian tube, or primary peritoneal cancer
- you are in a high risk ethnic group, such as having an 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 healthcare professional and facility that accepts Medicare.
Surgical options
There are two main types of surgery to treat breast cancer:
- mastectomy, which is the removal of the entire breast
- 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 people 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’re at high risk due to a genetic mutation.
There are several types of mastectomies. A doctor may recommend a specific type based on those factors.
To be sure that Medicare will cover your mastectomy, take the following steps:
- Ask your doctor to provide a written order stating you have a medical reason for a mastectomy.
- Be sure the wording in the order matches the 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 and external prostheses. These include:
- surgical implants
- exterior forms
- supportive garments, like mastectomy bras and camisoles
To check on coverage for specific items, visit Medicare’s website.
For both Medicare parts A and B, you are 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 doctors’ 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 of your mastectomy.
Medicare Part A
In 2024, 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 $1,632 for each benefit period. A benefit period is tied to a hospitalization, so you should meet your deductible from the mastectomy surgery alone.
There’s 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 $408 per day in out-of-pocket costs.
- Day 91 and beyond: The daily coinsurance cost rises to $816 per day for up to 60 days during your lifetime.
- After the 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 2024, the annual deductible for Medicare is $240.
- 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
Your costs for Part C 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.
All Medicare Part C plans have an annual out-of-pocket limit. Your monthly premium, deductible, copayments, and coinsurance all count toward this limit.
Medicare Part D
Medicare Part D is the prescription drug plan under Medicare. Costs for this plan also depend on the plan, the provider, and 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 2024 is $545. Copayments vary based on how much you spend in a year. There’s 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.
Starting in 2025, the yearly maximum out-of-pocket costs for prescription drugs will be capped at $2,000.
Medicare typically covers most of the costs associated with a mastectomy for cancer treatment or other medical needs.
Under normal Medicare rules for Medicare parts A, B, C, and D, you will be responsible for your share of the costs.
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.