Does Medicare Cover Breast Prosthesis and Bras?

Medicare Part B covers breast prostheses and related items, including mastectomy bras, for individuals who have undergone a mastectomy or lumpectomy. Understanding this coverage can help beneficiaries manage their post-surgical needs. This article clarifies Medicare’s coverage scope, eligibility requirements, the process for obtaining items, and associated costs.

Medicare Coverage for Breast Prostheses and Bras

Medicare Part B covers external breast prostheses, artificial breast forms worn after a mastectomy or lumpectomy. These are considered durable medical equipment (DME), defined as items that can withstand repeated use, are primarily for a medical purpose, and are appropriate for home use. Coverage extends to silicone and non-silicone prostheses, and related supplies like inserts or forms, when medically necessary.

Mastectomy bras are also covered by Medicare Part B when used to hold an external breast prosthesis in place. Medicare generally covers one breast prosthesis per side for its useful lifetime: typically two years for silicone prostheses, six months for fabric, foam, or fiber-filled prostheses, and three months for a nipple prosthesis. A prosthesis may be replaced sooner if lost or irreparably damaged, but not due to ordinary wear and tear. The quantity of mastectomy bras covered is determined by medical necessity as prescribed by a physician. An external breast prosthesis garment with a mastectomy form (L8015) is also covered for use in the postoperative period or as an alternative to a mastectomy bra and prosthesis.

Eligibility and Doctor’s Order Requirements

Eligibility for Medicare coverage of breast prostheses and bras depends on medical necessity following a mastectomy or lumpectomy. A doctor or authorized healthcare provider enrolled in Medicare must prescribe the items. A doctor’s order, often called a Standard Written Order (SWO) or prescription, is required for coverage. This order must include:

The beneficiary’s name
A description of the item
The quantity needed
The treating practitioner’s name or National Provider Identifier (NPI)
The date of the order and the practitioner’s signature

For certain DME items, including external breast prostheses, a face-to-face examination with the treating practitioner must occur within six months before the order is written. This ensures the practitioner has evaluated and documented the medical condition supporting the need. If a beneficiary’s medical condition changes, requiring a different type of breast prosthesis, a new order explaining the change is required from the treating practitioner. The written order must be provided to the supplier before the claim is submitted to Medicare.

Obtaining Your Items

After securing a doctor’s order for breast prostheses and mastectomy bras, find a Medicare-enrolled supplier, typically a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider. Select a supplier approved by and enrolled in Medicare, as Medicare generally does not cover items from non-enrolled suppliers. Present the doctor’s order to the supplier to verify the prescription and ensure items meet Medicare’s coverage criteria.

Ask if the supplier “accepts assignment,” meaning they agree to accept the Medicare-approved amount as full payment for the items. If they accept assignment, they bill Medicare directly, and the beneficiary pays the remaining deductible and coinsurance.

If a supplier does not accept assignment, they may charge more than Medicare’s approved amount. The beneficiary would be responsible for the difference, plus the deductible and coinsurance. In such cases, the beneficiary might pay upfront and then submit a claim to Medicare for reimbursement. While the supplier typically handles claim submission, beneficiaries should confirm this arrangement and be prepared to submit claims themselves if needed.

Understanding Your Costs

Beneficiaries incur out-of-pocket costs for Medicare-covered breast prostheses and bras. These items fall under Medicare Part B, which has an annual deductible that must be met before Medicare pays its share. For 2025, the Medicare Part B annual deductible is $257. After the deductible is met, Medicare Part B typically pays 80% of the Medicare-approved amount for the covered items. The beneficiary is responsible for the remaining 20% coinsurance. Original Medicare has no annual out-of-pocket maximum limit, so coinsurance costs can accumulate. Medicare also has frequency limits on item replacement. While Medicare does not specify a quantity limit for mastectomy bras, the number covered must be medically necessary. Discuss all potential costs and replacement schedules with the supplier before obtaining items to avoid unexpected expenses.

Medicare Advantage Plans

Medicare Advantage Plans (Medicare Part C) offer an alternative way to receive Medicare benefits through private insurance companies. These plans must cover at least the same benefits as Original Medicare, including breast prostheses and mastectomy bras. However, Medicare Advantage plans can have different rules regarding costs, networks, and prior authorization.

Beneficiaries should contact their specific plan to understand coverage details, including deductibles, copayments, or coinsurance amounts, as these may differ from Original Medicare. Inquire about network restrictions, such as preferred suppliers, as using out-of-network providers may result in higher out-of-pocket costs or no coverage. Some Medicare Advantage plans may also require prior authorization for certain durable medical equipment before acquisition.