Does Medicare Cover Breast Reconstruction Surgery?

Medicare Benefits Solutions
Apr 11, 2021

If you have had a mastectomy, or are about to have one, you aren’t alone. In 2020 in the United States, over a quarter-million women were diagnosed with invasive breast cancer.

Typically, over 100,000 women have a mastectomy of some type every year. Not all mastectomies are due to a breast cancer diagnosis, some are performed as a proactive measure to lower the risk of getting breast cancer.

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Breast Cancer Statistics

Statistics show that the greatest risk factor for getting breast cancer is age. In fact, 50 percent of new cases generally occur in women between 50 and 69 years old. That risk is even higher when women are between 60 and 70 years of age.

Whether you’ve had a mastectomy or are preparing for one, your physician may have discussed your options for breast reconstruction surgery. Reconstruction surgery can be done during your mastectomy procedure or after – even months or years later.

If you have Medicare insurance, your benefits may cover all, or a portion of, your expenses for breast reconstruction surgery. This article explains how your Medicare benefits can help you.

Medicare and Breast Reconstruction Surgery

If you have coverage through Original Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), or through a Medicare Advantage (Part C) plan, you have coverage for surgical procedures that are deemed medically necessary.

Your Medicare Part A benefits cover the procedure of surgically implanting breast prostheses if it takes place in an inpatient setting. To be eligible for this coverage, you must have the procedure done in a facility or hospital that accepts Medicare assignment. Also, the procedure must follow a mastectomy due to having breast cancer.

If you have your breast prosthesis implantation surgery done as an outpatient, your Medicare Part B benefits cover a portion of the cost for the procedure. To be eligible you must have it done by a physician that accepts Medicare and in a facility or hospital that also accepts Medicare assignment. You must also have had a mastectomy due to breast cancer.

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Medicare Advantage Breast Reconstruction Surgery

If you have coverage with a Medicare Advantage plan, your provider may require that you have the procedure done by a physician who is in the plan’s network of providers. You may also need to use a hospital or medical facility within the network. If you aren’t certain about the requirements, you should discuss the details with a plan representative.

Medicare benefits typically don’t cover cosmetic surgery, so if you have breast reconstruction surgery for other reasons other than after a mastectomy for breast cancer, you pay 100 percent of the cost for services.

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What is the Cost of Breast Reconstruction Surgery?

If you have your procedure done as an inpatient under Part A, you must have previously paid your Part A deductible. In 2021, this amount is $1,484.00 per benefit period. Your coinsurance costs are $0.00 for days 1-60. If your stay extends beyond 60 days, the coinciding coinsurance costs apply.

If you have the procedure done as an outpatient under Part B, Medicare pays for 80 percent of the final, approved cost and you pay the remaining 20 percent. You are also responsible for your Part B deductible ($203.00 in 2021) and your monthly premium (148.50 in 2021).

If you are enrolled in a Medicare Advantage plan, you will have at least the same coverage as Original Medicare Part A and Part B, but many MA plans include additional benefits.

Reconstructive Surgery Cost Without Insurance

If you have been diagnosed with breast cancer and have a partial or full mastectomy, you may be eligible for breast reconstruction surgery. If you don’t have coverage through Medicare or other health care insurance, the national average cost for surgery runs between $25,000.00 and $50,000.00 per breast. Your final cost depends on the type of reconstruction surgery you have and where you have it done.

To get more information about breast reconstruction surgery after a mastectomy, you can discuss your concerns with your health care provider or call your plan directly. A licensed agent can give you details about your coverage options.

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