Does Medicare Cover Breast Implants After a Mastectomy?
This article was updated on: 10/20/2018
What is a mastectomy?
According to the Mayo Clinic, a mastectomy may be a treatment option for those with early-stage breast cancer or those who wish to prevent breast cancer. A simple mastectomy removes the breast tissue, nipple, areola and skin but not all the lymph nodes. A modified radical mastectomy removes all that a simple mastectomy removes as well as most of the underarm lymph nodes, according to the Mayo Clinic. A doctor may also perform a skin-sparing mastectomy and a nipple-sparing mastectomy. Breast reconstruction to restore the shape of the breast may be done at the same time as the mastectomy or as a second operation. According to breastcancer.org, during breast reconstruction a plastic surgeon creates a breast shape with an artificial breast implant or a flap of tissue from another place in your body. A nipple can be created 3 or 4 months after the breast implant with either tissue reconstruction or a nipple tattoo.
Does Medicare cover breast implants after a mastectomy?
If you lose one or both breasts in a mastectomy, Original Medicare will generally cover breast implants. If you receive a surgically implanted breast prosthesis in an inpatient setting, Medicare Part A will generally cover it. If you receive breast reconstruction in an outpatient setting, Medicare Part B will generally cover it.
According to breastcancer.org, some women prefer an external prosthesis that they can take on and off instead of having breast reconstruction surgery. Medicare Part B usually covers external breast prostheses including a post-surgical bra after mastectomy. A post-surgical bra differs from a regular bra in the way that it may have a pocket to hold the breast prosthesis. Some external breast prostheses are attachable directly to the skin.
If you have Medicare Advantage plan it also will generally cover the breast implants and external breast prostheses explained above. A Medicare Advantage plan offered by a private insurance company must cover everything that Medicare Part A and Part B cover except for hospice care, which is still covered by Part A.
How much do breast implants cost with Medicare?
- If you receive breast implants in an outpatient setting, you generally pay 20% of the Medicare approved amount and the Part B deductible applies.
- If you receive breast implants in an inpatient setting, you pay the Part A hospital costs.
- If you receive an external prosthesis, you generally pay 20% under Medicare Part B.
A Medicare Supplement plan offered by a private insurance company may help you cover these out-of-pocket costs.
What are other situations where Medicare may cover breast implants?
- Medicare may cover breast implants as part of a sex reassignment surgery on a case by case basis if you are at least 18 years old and have a documented case of gender dysphoria. According to the American Psychiatric Association, gender dysphoria involves a conflict between a person’s physical or assigned gender and the gender with which they identify.
- Medicare generally does not cover breast implants as part of a cosmetic procedure not related to a mastectomy or sex reassignment surgery. Typically, Medicare does not cover cosmetic procedures unless they are part of an accidental injury or are to improve a malformed part of the body.
- Medicare usually does not cover breast implant removal unless it qualifies as a covered cosmetic surgery.
Do you have more questions about Medicare coverage of breast implants?
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