Does Medicare Cover Breast Reconstruction After Lumpectomy?

A lumpectomy involves the surgical removal of a cancerous tumor and a small margin of surrounding healthy tissue from the breast. Following this procedure, breast reconstruction aims to restore the breast’s appearance, shape, and symmetry. This process can involve various surgical techniques to rebuild the breast mound. This article clarifies Medicare’s coverage policies for breast reconstruction after a lumpectomy, including specific regulations and medical necessity criteria.

General Medicare Coverage

Medicare generally provides coverage for breast reconstruction following a medically necessary lumpectomy, considering it a reconstructive surgery rather than a cosmetic one. This coverage falls under Medicare’s National Coverage Determination (NCD) 140.2, which broadly applies to breast reconstruction after a mastectomy, including partial mastectomies like lumpectomies.

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Part A typically covers inpatient hospital care, including facility costs. Part B covers physician services, outpatient hospital services, and certain medical supplies, such as external prostheses and post-surgical bras.

Medicare Advantage plans, also known as Part C, are offered by private companies approved by Medicare and must provide at least the same level of coverage as Original Medicare (Parts A and B). While these plans cover breast reconstruction, their specific rules regarding costs, networks, and prior authorization can differ from Original Medicare. Beneficiaries should consult their specific plan for details on out-of-pocket expenses and network requirements.

Detailed Coverage Requirements

Medicare’s coverage for breast reconstruction after a lumpectomy extends to situations where the procedure is considered medically necessary to address disfigurement or asymmetry resulting from the cancer treatment. This includes reconstruction of the breast where the lumpectomy was performed, as well as surgery on the opposite breast to achieve a symmetrical appearance. The Women’s Health and Cancer Rights Act (WHCRA) of 1998 mandates coverage for all stages of reconstruction following a mastectomy, which includes lumpectomy.

Medical necessity means the reconstruction is performed to restore function or appearance after illness, not purely for aesthetic enhancement. Covered services can encompass various techniques, such as the use of tissue expanders, silicone or saline implants, and flap procedures using the patient’s own tissue.

Medicare also covers related services. This includes anesthesia administered during the surgery, hospital stays, and follow-up care. Coverage may also extend to external breast prostheses, post-surgical bras, and the treatment of physical complications arising from the lumpectomy or reconstruction, such as lymphedema.

The timing of reconstruction, whether immediate (at the time of lumpectomy) or delayed (at a later date), does not affect Medicare coverage. Revisions to previously reconstructed breasts are also covered to correct complications or improve outcomes.

Steps to Access Coverage

Accessing Medicare coverage for breast reconstruction after a lumpectomy begins with a consultation with your treating physician and a plastic surgeon. These medical professionals will determine the medical necessity of the reconstruction based on the extent of tissue removal and the resulting disfigurement or asymmetry. Documentation of the medical rationale is crucial for coverage approval.

Prior authorization may be necessary before proceeding with the surgery. The provider’s office typically handles this process by submitting the required documentation to Medicare or your Medicare Advantage plan. Securing prior authorization helps confirm coverage and can prevent unexpected out-of-pocket costs.

With Original Medicare, beneficiaries are responsible for deductibles and coinsurance, which is 20% of the Medicare-approved amount for Part B services after meeting the annual deductible. For inpatient services covered under Part A, a deductible applies per benefit period. Supplemental insurance plans, such as Medigap, can help cover these out-of-pocket expenses, while Medicare Advantage plans may have different cost-sharing structures, including copayments, coinsurance, and annual out-of-pocket limits.

After the services are rendered, providers will submit claims to Medicare on your behalf. Beneficiaries should review their Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) from their Medicare Advantage plan to ensure accuracy and understand what was billed and paid. These statements detail the services received, the amounts charged, and the portion Medicare paid, along with any remaining balance the beneficiary owes.

In the event a claim for breast reconstruction is denied, beneficiaries have the right to appeal the decision. The appeals process involves several levels, starting with a redetermination by Medicare, followed by reconsideration by an independent review entity. Providing additional medical documentation or clarification from your physician can strengthen an appeal.