Does Medicare cover breast reconstruction?
For breast cancer survivors, breast reconstruction is more than just a surgical procedure—it’s a deeply personal, emotional, and transformative experience. Breast reconstruction involves reshaping or replacing the breast with a prostheses after removing a cancerous lump (lumpectomy) or the entire breast (mastectomy).
We’re happy to share that Medicare covers breast implants, post-surgical bras, and reconstruction if you’ve had a mastectomy due to breast cancer. In this guide, we’ll walk you through what the breast reconstruction process looks like and how Medicare coverage works for it.
Key takeaways:
Medicare covers breast reconstruction, including surgery for breast implants and skin grafting, if you had a mastectomy due to breast cancer.
Costs for breast reconstruction vary, based on your specific Medicare coverage.
What is breast reconstruction?
Breast reconstruction involves rebuilding the shape of your breast to create a natural appearance. People typically seek breast reconstruction after experiencing a serious injury, mastectomy, or lumpectomy. Breast reconstruction can help you regain confidence and help you feel more like yourself again after a great period of stress.
What is involved in breast reconstruction?
Because breast reconstruction occurs after removing a lump or the entire breast, you’ll need time to recover before going through the procedure.
Once you recover, breast reconstruction could involve:
Making and replacing a new breast by grafting tissue from another body part
Inserting silicone gel or foam implants to replace the breast
A combination of both tissue grafting and implants
Wearing a post-surgical bra for added comfort while the area heals
You can expect to have a thorough consultation with your surgeon before going through the surgery. During this meeting, you’ll discuss your medical history, personal preferences, and potential risks with the procedure. The consultation is meant to help you feel confident about going into breast reconstruction so you know what to expect when the reconstruction is complete.
After the breast reconstruction surgery, you may need to stay in the hospital for a period of time so healthcare providers can make sure you’re healing properly. It’s likely that you’ll have to wear a surgical bra to support you and reduce swelling. Your provider will recommend medications to manage pain and make the recovery process easier.
Does Medicare cover breast reconstruction after lumpectomy?
Medicare does not cover breast reconstruction after a lumpectomy, which is a procedure to remove a cancerous lump or tissue from your breast. This could be because breast reconstruction surgery may not always be necessary following a lumpectomy. While Medicare doesn’t explicitly say that it covers breast reconstruction after a lumpectomy, it’s worth having a conversation with your medical provider and insurance carrier to discuss your specific situation and see if you can get prior authorization.
Does Medicare cover breast reconstruction after mastectomy?
Medicare covers breast reconstruction after a mastectomy, a procedure that removes a breast to treat breast cancer. This includes coverage for a double breast reconstruction after a double mastectomy.
What Medicare covers:
Some external breast prosthesis, an artificial breast that you put inside your bra to replace your breast
A post-surgical bra that you can wear after the breast reconstruction surgery for added comfort while healing
Silicone or foam breast implants and the surgery to implant them
Surgery to reshape the breast with skin grafting
How much you pay for breast reconstruction with Medicare
With Original Medicare, you’ll pay 20% of the Medicare-approved amount for any breast reconstruction procedures or materials. Having a Medicare Supplement plan will reduce your out-of-pocket expenses related to breast reconstruction services.
Medicare Advantage plans cover the cost of breast reconstruction, but how much you pay out-of-pocket for copays, coinsurance, or deductibles will depend on the specific policy you have. Communicate with your medical provider and insurance carrier to make sure you get any necessary prior authorizations and understand what you’ll owe before you undergo surgery.
Lastly, your Medicare drug plan (Part D), is responsible for any medications you need following the surgery to manage pain or healing. Because plans and their covered drug lists vary, it’s important to communicate with your provider to ensure your prescriptions are covered by your plan.
If you’re thinking about breast cancer reconstruction, you’ve already been through a lot. Paying for the procedure should be the last thing on your mind. We’re here to help! Speak with one of our licensed Medicare Advisors, who can help you understand your coverage and what you can expect to pay for your breast reconstruction. Call 855-900-2427 or schedule a time to chat to get your Medicare questions answered.