Does Medicare Cover a Biopsy?
Last Updated : 11/11/20194 min read
If your doctor has identified an area of concern that may be cancer, you may have to have a biopsy. Your first question is probably, “What is a biopsy?” and your second may be, “Will Medicare cover a biopsy?”
Here’s some information to help answer those questions.
What is a biopsy?
A biopsy is any procedure in which your doctor removes some tissue or cells from an area of your body. The tissue or cell sample is then sent to a pathologist to be analyzed for signs of cancer. According to the U.S. National Library of Medicine, a biopsy is generally the only test that can show with certainty if cancer is present. The word “biopsy” is from the Greek words “bio,” meaning “life” and “opsis”, which means “sight” according to Dictionary.com.
How is a biopsy performed?
The Mayo Clinic describes several different biopsy types your doctor may use to diagnose cancer, depending on where the suspicious area is located. Here are a few you may encounter:
- A bone marrow biopsy is used to check for blood cancers and other disorders. Your doctor will use a needle to remove marrow from a bone, generally your hip bone.
- An endoscopic biopsy is used to get tissue samples from your lungs, colon, bladder, rectum, and other organs. The doctor uses a thin, flexible scope to see the organ and collect tissues or cells for a biopsy.
- A needle biopsy takes a sample of suspicious cells beneath the skin, such as a breast or lymph node.
- A skin biopsy is often used to diagnose skin cancers. Your doctor will shave, punch, or excise (cut away) a bit of tissue for lab analysis.
- A surgical biopsy is used when your doctor can’t access the suspicious area using any other method. The doctor makes an incision in your skin to see the suspicious cells and then removes all or part of them during the surgical procedure. You may have to stay in the hospital overnight depending on the type of surgical biopsy you have.
Once the tissue or cells are removed, they go to the laboratory for analysis by a pathologist. In some cases, your doctor will get the results within minutes, although most of the time, you may have to wait a few days to see the results according to the Mayo Clinic. Your doctor should tell you when you can expect the results from your biopsy.
Does Medicare cover a biopsy?
In general, Medicare does cover all medically necessary treatment for cancer, which may include a biopsy to diagnose your cancer. Under Original Medicare (Part A and Part B), your doctor visits, laboratory tests, and outpatient procedures are covered under Part B, while your care as an inpatient in the hospital is covered under Part A. You will have to meet your Part A and Part B deductibles, and there is generally a 20% coinsurance amount on allowable charges for covered services under Part B. You may have other copayments and coinsurance amounts, as well.
If you are covered by a Medicare Advantage plan, which is simply an alternative way to get your Medicare benefits, your medically necessary biopsy should also be covered. All Medicare Advantage plans are required by law to offer the same coverage, at a minimum, as Original Medicare. You may also have extra benefits such as routine vision and dental services through Medicare Advantage and hospice care is still covered by Medicare Part A.
Prescription medications and anesthetics administered by your doctor prior to and during your biopsy, whether in an outpatient or hospital setting, are generally covered by Medicare. If you are prescribed medications to take at home, these are generally not covered, unless you have Medicare Part D coverage for prescription drugs. You can get Part D Prescription Drug coverage through a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage.
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