Does Medicare cover double mastectomy? Let’s find it out!

A recent study found that annually over 100,000 American women undergo a mastectomy.

Mastectomy is a common method of treating breast cancer. However, it is not necessary for everyone who has one. Single mastectomies involve the removal of only one breast, while double mastectomies involve the removal of both breasts.

Upon receiving a cancer diagnosis, Medicare will often pay for most necessary treatments, including a mastectomy. Medicare will not pay for a mastectomy if the surgery is not medically necessary.

Let’s find out when Medicare covers a double mastectomy.

Mastectomy—what is it?

The procedure is called a mastectomy when one or both breasts are medically removed due to cancer. Mastectomy procedures vary depending on the underlying cause. The most typical examples include:

A total mastectomy, sometimes known as a “simple” mastectomy, is when a breast is completely removed without the underlying muscles being cut.

The removal of both breasts is known as a “double” or “bilateral” mastectomy.

Radical mastectomy removes the arm lymph nodes, breast and chest wall muscles.

Only the chest wall muscles are kept intact in modified radical mastectomy.

Mastectomies depend on the patient’s age, tumor size, stage of menopause, health, grade, lymph node involvement, stage, and hormone sensitivity.

There will be at least a three-day hospital stay following a mastectomy, possibly more if reconstructive surgery is performed simultaneously. At home, a full recovery usually takes a few weeks. Upon visiting the doctor, you will receive a detailed recovery plan.

What exactly is a double mastectomy?

A double mastectomy, also called a bilateral mastectomy, is a mastectomy in which both breasts are surgically removed simultaneously.

To treat breast cancer or prevent it in high-risk women, both breasts can be removed. A prolonged recuperation time, anywhere from a few weeks to several weeks, may be necessary after a brief hospital stay.

Types of Mastectomy Surgery

Different mastectomies have different goals and methods. Once Medicare determines that a service is medically required, payment will be made for it.

A total (simple) mastectomy

This method excises the breast, including the nipple, areola, and most of the skin.

Double (or bilateral) mastectomy

A double mastectomy removes both breasts through a simple mastectomy or, in certain situations, a nipple-sparing mastectomy.

Skin Sparing Mastectomy 

A skin sparing mastectomy removes the areola, nipple, and breast tissue, but preserves breast skin. Also, this method is solely used to restore breasts after mastectomy.

Nipple-Sparing Mastectomy 

This procedure removes the ducts, breast, and areola like the skin-sparing mastectomy. Nipple and areola preservation depends on the absence of cancer cells in the vicinity. Otherwise, you shouldn’t use this approach.

Radical Mastectomy

These operations are currently quite uncommon. The breast, lymph nodes, and chest muscles are all taken out by the surgeon. This procedure can still be done for big tumors that have spread into the pectoral muscles.

When selecting a surgeon and hospital for surgery, check to see if they accept Medicare patients.

Medicare Advantage plans may limit you to network doctors and hospitals. Patients on Medicare Advantage will need to get approval for the procedure ahead of time.

Does Medicare Cover Mastectomy?

Breast cancer patients who need a mastectomy to treat their disease are not out of luck, as Medicare covers nearly all cancer therapies.

Women’s breasts are removed during a mastectomy. A lumpectomy is a similar operation in which the affected portion of the breast and some surrounding healthy tissue are excised.

The Medicare Part B deductible and coinsurance amounts vary depending on many criteria, including the surgical facility.

Medicare also pays for reconstructive surgery.

After a mastectomy, you might need certain items. Medicare will pay for some of these items, but not all of them.

Visits to the doctor and outpatient care

Medicare Part B covers outpatient care. The program covers outpatient mastectomy surgery and oncologist follow-ups.

Inpatient surgery and treatment

Medical care received when a patient is a patient at a hospital is covered by Medicare Part A. This benefit will cover your mastectomy and any necessary hospitalization.

Reconstruction

If you decide to have reconstruction following a mastectomy, Medicare Part A will pay for your prosthesis. After a mastectomy, external prosthesis and post-op bras are covered under Medicare Part B.

Medicare Advantage plans or Part C similarly cover parts A and B. However, depending on your plan, you may be eligible for additional prescription drug coverage and other perks.

Medications

Medicare Part A covers hospital medicines and Part B covers outpatient oral chemotherapy.

If you need other mastectomy drugs, you need a Medicare Part D or Medicare Advantage plan with prescription coverage. If not, you might have to fork over your own cash.

Your Medicare Part D coverage should cover medications for postoperative nausea, discomfort, and other symptoms. Your Part D plan’s coverage and premiums will be determined by your provider and where you live.

Genetic testing and Prophylactic mastectomy

Medicare covers elective mastectomies less easily than cancer treatments. Medicare does not cover preventive mastectomy. Medicaid in your state may cover it.

Cosmetic surgery is not Medicare-covered.

If you have a genetic mutation or a breast cancer family history, you may want a mastectomy. If Medicare denies coverage, ask your doctor for more information and written documentation.

Medicare covers BRCA1 and BRCA2 gene mutation tests but not genetic testing. Medicare will cover BRCA testing if you have a family history of breast cancer and one of these conditions:

  • You had two primary breast tumors before 45, with or without a family history, or before 50.
  • You had two primary breast cancers when diagnosed before 50, breast cancer at any age, and at least two close blood relatives with certain other cancers.
  • You’re Ashkenazi Jewish, have a close relative with a BRCA1 mutation or BRCA2, or have had a primary peritoneal cancer, fallopian tube, or epithelial ovarian.

Only doctors who accept Medicare patients are allowed to perform genetic testing. Breast cancer risk is reduced by 90% in women who carry the BRCA1 or BRCA2 gene mutations and undergo preventative mastectomy.

What will my out-of-pocket expenses be?

Mastectomy-related Medicare Parts A and B deductibles, coinsurance, and copayments are your responsibility. After meeting the Part B deductible, patients pay 20% of Medicare-approved costs for doctor visits and external prostheses.

A Medicare supplement plan, generally known as Medigap, can cover most out-of-pocket expenses associated with a mastectomy.

Part A

Out-of-pocket costs for Part A include:

  • Each benefit period has a $1,408 deductible.
  • The first 60 days of a benefit period are coinsurance-free.
  • Benefit periods 61–90 have $352 coinsurance.

An individual’s benefit period begins when they enter a hospital and concludes on the day they have been discharged for 60 consecutive days.

Part B

The out-of-pocket costs for Part B are:

  • The regular payment is $144.60 each month.
  • The typical yearly deductible for a family is $198.
  • Copayments of 20%

Part C

Your Medicare Part C premium will be established by the plan you select. Private Medicare Part C insurance plans often include prescription drug coverage and all the benefits of Original Medicare.

The maximum amount you’ll have to pay yearly is $6,700 with any Medicare Part C plan. This maximum sum includes the monthly premium, deductible, copayments, and coinsurance you are responsible for paying.

Part D

Medicare covers prescriptions under Part D. Prices for this strategy vary for where you live and the specific strategy and supplier you select.

Private insurers may sell these products with varying prices and coverage options despite Medicare’s regulations. As with other insurance policies, the cost of your prescription drugs will be covered partly by your monthly premium, a yearly deductible, and a copayment that varies from plan to plan.

Medicare Part D maximum deductible was $435 last year. Your annual spending will determine your copayment amount. The cost of your prescriptions may also be affected by the coverage gap. There comes a time when your expenses exceed the limit of your catastrophic coverage. After that, your prescription drug prices for the remainder of the year will be significantly reduced.

Bottom Line

To sum up, a double mastectomy and other breast cancer therapies like chemotherapy, radiation therapy, and prosthesis implantation are covered by Original Medicare and Medicare Advantage.

Both types of Medicare come with expenses such as deductibles, copays, and coinsurance. Some of these costs are covered if an individual with original Medicare has Medigap coverage.

If you are considering getting a double mastectomy, you may want to check your Medicare plan to find out what it covers and how much it will cost.

FAQS

Who is eligible for a double mastectomy?

A bilateral mastectomy is an option for women with many tumors, a history of chest radiation (before age 30), or pregnancy.

Can insurance refuse a double mastectomy?

If a woman wishes to remove both healthy breasts to lower her breast cancer risk or has a mastectomy to treat breast cancer in one breast, these insurers may deny coverage.

How long is a double mastectomy hospital stay?

The average time spent in the hospital after the operation is one to three days, with a follow-up appointment scheduled for one to two weeks afterward; however, this time frame can increase with a more sophisticated procedure or the addition of rapid reconstructive surgery. A delayed reconstruction or no reconstruction at all is also an option.

What’s the life expectancy after a double mastectomy?

The 10-year survival rate after a mastectomy and radiation treatment is 83.2%. A single mastectomy had 79.9% 10-year survival. 81.2% survive 10 years after double mastectomy.

Do double mastectomy patients keep their nipples?

The nipple is often removed along with the breast when a mastectomy is performed to treat breast cancer. (The nipple can be preserved in a mastectomy by leaving it unremoved in some women.

Is a double mastectomy worthwhile?

For early-stage breast cancer, most specialists do not advise a double mastectomy. Women who undergo a double mastectomy do not fare better in terms of survival than those who opt for a lumpectomy plus radiation therapy. A double mastectomy mitigates only the chance of developing a second breast cancer.