Does Medicare Cover Mastectomy and Reconstruction?

Medicare, a federal health insurance program, provides coverage for mastectomy procedures and subsequent breast reconstruction. This coverage recognizes the medical necessity of these interventions.

Mastectomy Surgery and Reconstruction

Medicare covers mastectomy surgery, which can include various types such as lumpectomy, partial, total, or radical mastectomy. For inpatient hospital stays related to mastectomy surgery, Medicare Part A (Hospital Insurance) provides coverage. This includes hospital room, meals, nursing care, and medications received during the inpatient stay. If the mastectomy is performed in an outpatient setting, Medicare Part B (Medical Insurance) covers the outpatient surgery, physician services, and other medical services provided in a hospital outpatient department.

Breast reconstruction surgery following mastectomy is also covered by Medicare, as it is considered reconstructive rather than cosmetic. This coverage applies to both the affected breast and, when necessary to achieve symmetry, the unaffected breast. Procedures covered can include implant-based reconstruction, tissue flap procedures, and surgeries to address complications from previous reconstruction. Medicare Part A covers surgically implanted prostheses if the reconstruction occurs during an inpatient hospital stay, while Part B covers outpatient reconstruction.

Post-Surgical Care and Related Supplies

Following mastectomy surgery, Medicare Part B provides coverage for post-surgical items and services. This includes external breast prostheses, also known as breast forms, which can be used if a person chooses not to undergo or delays reconstructive surgery. Medicare Part B also covers mastectomy bras designed to hold these prostheses in place, if medically necessary and prescribed by a doctor. Medicare covers one breast prosthesis per side for its lifetime, with specific durations defined for different types, such as two years for silicone prostheses and six months for fabric or foam versions.

Medicare Part B also covers related post-surgical therapies. This includes physical therapy and occupational therapy. Lymphedema treatment, a common complication after mastectomy, is also covered under Part B when medically necessary.

Prescription Drugs

Prescription medications are covered under Medicare Part D (Prescription Drug Coverage). This includes pain management medications, anti-nausea drugs, and other necessary pharmaceuticals. Each Part D plan has a formulary, which is a list of covered drugs. Beneficiaries should verify their specific medications are included.

Part D plans involve premiums, deductibles, and copayments or coinsurance, which vary by plan. For 2025, the standard Part D deductible is $590, though some plans may have a lower or no deductible. A significant change for 2025 is the elimination of the coverage gap, often called the “donut hole,” and the implementation of a $2,000 annual cap on out-of-pocket spending for covered drugs. Once this $2,000 limit is reached, the plan covers 100% of the cost of covered medications for the remainder of the year.

Medicare Advantage and Medigap Plans

Medicare beneficiaries have options beyond Original Medicare, including Medicare Advantage (Part C) and Medigap (Medicare Supplement Insurance) plans. Medicare Advantage plans are offered by private insurance companies and must provide at least the same coverage as Original Medicare Parts A and B, including mastectomy and reconstruction services. These plans may have different cost-sharing rules, provider networks, and may offer additional benefits not found in Original Medicare, such as prescription drug coverage.

Medigap policies do not provide additional benefits but help cover out-of-pocket costs associated with Original Medicare. These policies can help pay for expenses like deductibles, copayments, and coinsurance that Original Medicare does not cover. Unlike Medicare Advantage plans, Medigap policies are designed to supplement Original Medicare and do not replace its coverage.

Understanding Your Financial Responsibilities

While Medicare provides coverage for mastectomy and reconstruction, beneficiaries are responsible for certain out-of-pocket costs. For inpatient hospital stays covered by Medicare Part A, the deductible for each benefit period is $1,676 in 2025. Beyond the first 60 days of an inpatient stay, a daily coinsurance applies, amounting to $419 per day for days 61-90 and $838 per day for lifetime reserve days in 2025.

For services covered by Medicare Part B, such as outpatient surgery, doctor’s visits, and durable medical equipment, beneficiaries must meet an annual deductible, which is $257 in 2025. After meeting this deductible, Medicare pays 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance. For prescription drugs covered by Medicare Part D, beneficiaries are responsible for monthly premiums, deductibles, and copayments or coinsurance, up to the annual out-of-pocket cap.