Mastectomy is commonly performed to treat or prevent breast cancer. But, despite its life-saving nature, mastectomy isn’t affordable at all. 

It can cost you anywhere from $15,000 to $55,000 in the US. That’s a lot of money!

So, if your doctor has suggested a mastectomy, you must be concerned about whether Medicare covers the cost or not. 

Well, don’t worry because today’s post is all about Medicare mastectomy coverage. We’ll discuss everything from the types of mastectomy covered to the final cost you’ll have to pay. 

Is mastectomy covered by Medicare? 

Breast cancer is a type of cancer that forms in the cells of the breast. It is characterized by the uncontrolled growth and multiplication of abnormal cells within the breast tissue. 

Although it can occur in both men and women, it is much more common in women. In fact, the Centers for Disease Control and Prevention (CDC) classifies it as the second most common type of cancer in American women!

Fortunately, Medicare covers mastectomy – a surgery to remove all or some of the affected tissues from the breast. But exactly how much Medicare will pay for the surgery depends on several factors:

• Type of mastectomy
• Your Medicare plan
• Where the procedure takes place

In case you’re wondering about eligibility, Medicare offers “medically necessary” coverage to all breast cancer patients. This means it will provide all healthcare services that are needed to diagnose or treat the condition and its symptoms. 

Medicare will not cover breast cancer preventative surgeries and supplies for any beneficiary. It will also not cover any breast cosmetic surgery until it is medically necessary. 

Does Medicare cover double mastectomy?

Yes, Medicare covers double mastectomy. It involves the complete removal of breast tissue, including the nipples and areolas, from both breasts. Some people also refer to it as bilateral mastectomy.

But that’s not the only type.

There are several types of mastectomies, each involving the removal of varying amounts of breast tissue. Here are some other types of mastectomies covered by Medicare:

1. Total or Simple Mastectomy

A Total or Simple Mastectomy involves removing the entire breast, including the nipple, areola, and most of the skin covering it. It doesn’t include the removal of lymph nodes or muscles under the breast. 

Doctors may suggest this method for individuals with multiple cancers or extensive cancer in the milk ducts. 

2. Skin-Sparing Mastectomy

A skin-sparing mastectomy removes the breast tissue while preserving most of the overlying skin. The nipple and areola are typically removed, but the rest of the skin covering the breast is spared. This technique allows for better cosmetic outcomes and is often used in combination with breast reconstruction surgery.

3. Nipple-Sparing Mastectomy

A nipple-sparing mastectomy is very similar to a skin-sparing mastectomy. In this, the breast tissue is removed as well as the ducts to the areola and nipple. But, the actual nipple and areola are preserved. 

This technique is commonly used for individuals with early-stage breast cancer when the disease hasn’t spread out into surrounding structures. It allows for a more natural-looking result after reconstruction.

4. Radical Mastectomy

A radical mastectomy is an extensive surgical procedure. It involves the removal of the entire breast, along with the underlying chest muscles (pectoral muscles) and lymph nodes in the underarm area.

This procedure was once commonly performed for advanced breast cancer but is now rarely used due to less invasive treatment options. But a doctor may still recommend it if the breast cancer has spread to your chest muscles. 

5. Modified Radical Mastectomy 

A modified radical mastectomy combines elements of both total mastectomy and axillary lymph node dissection. This means the entire breast will be removed along with some of the lymph nodes in the underarm area (axillary lymph nodes). 

But the chest muscles will be left intact, unlike in a radical mastectomy. It is recommended for women whose breast cancer has spread to the lymph nodes.

Does Medicare cover prophylactic Mastectomy? 

Prophylactic mastectomy is a preventive surgical procedure to remove one or both breasts in individuals who have a high risk of developing breast cancer but have not been diagnosed with the disease. 

It is done to reduce the risk of breast cancer occurrence. People who might consider prophylactic mastectomy include those with:

• A strong family history of breast cancer
• Certain genetic mutations (e.g., BRCA1 or BRCA2)
• A personal history of previous breast cancer in one breast

Since this type of mastectomy is not “medically necessary”, Original Medicare does not provide any coverage for it. You’ll have to pay for it from your pocket. 

However, if you have a Medicare Advantage plan (also called Part C), you may want to check with the plan provider since some MA plans do cover prophylactic mastectomies and other preventative surgeries. 

If you are considering a prophylactic mastectomy, it’s best to first get a complete evaluation from your healthcare provider and explore the options available. It’s possible that you may not need it at all. 

Does Medicare cover reconstructive surgery after mastectomy? 

Mastectomy involves the removal of breast tissues, and for many women, breast reconstruction can be an important part of the physical and emotional recovery process. So, yes, Medicare covers reconstructive surgery after mastectomy. 

In this procedure, the appearance of the breast(s) is restored using various techniques. These include silicone-gel implant filling and grafting (placing tissue from another part of the body into breast tissues to encourage new growth). 

This recreates a natural-looking breast shape to help improve body image and quality of life for the patient. However, since this is highly personal, your doctor won’t make it necessary to undergo the surgery. 

In fact, about 35% of breast cancer survivors don’t choose breast reconstructive surgery after mastectomy. Some feel more comfortable with a flat chest, while others don’t wish to trigger further complications in their health. 

Whatever the reason may be, it’s best to think this decision through and discuss it with your healthcare providers. Your breast reconstructive surgery can take place immediately after mastectomy or once you’ve fully recovered from cancer. 

So, how much do you pay for a mastectomy with Medicare? 

Now that we have discussed what types of mastectomy Medicare covers. Let’s have a look at how much coverage you will actually receive in each plan!

Medicare Part A 

Original Medicare offers 100% coverage for mastectomy in Part A. However, you must meet the following requirements:

• You’re undergoing inpatient surgery. 
• You have paid the $1632 deductible for your benefit period (in 2024).
• You will be paying 20% of the doctor’s fees inside the hospital.

This means if you won’t be staying at the hospital, you won’t qualify for Part A coverage. You will also not receive 100% coverage if the $1632 deductible isn’t spent or 20% of the doctor’s fees aren’t paid.

If those fees are paid, Medicare will be responsible for all mastectomy expenses for the first 60 days at the hospital. You will have to afford days after that on coinsurance. 

In 2024, the coinsurance amount for hospitalization days (61 to 90) is $408 per day. Meanwhile, the amount for lifetime reserve days is $816 per day.

That being said, Part A will also cover expenses for necessary home healthcare, skilled nursing facility care, and breast prostheses after a mastectomy in an inpatient setting.

Medicare Part B 

Part B is for Original Medicare beneficiaries who opt for outpatient surgery. This means you won’t be formally administered at the hospital. Instead, you’ll have your mastectomy and leave the hospital on the same day. 

In this plan, Medicare will cover 80% of all the expenses while you will afford the remaining 20%. So, you will pay 20% of the following costs:

• Outpatient mastectomy surgery
• Surgeon, doctor, and other involved health care provider’s fees
• X-rays and other necessary lab tests
• Anesthesia
• Medical supplies and drugs provided during the treatment

Please note, Part B also provides coverage for any medical supplies you may need after a mastectomy. This means mastectomy bras, camisoles, breast prostheses, and all other post-surgery equipment will be covered.

But you will pay 20% of the amount, regardless of how many times you need it. 

Part C (Medicare Advantage)

Part C is offered by private companies under the name Medicare Advantage plan. It includes all Part A and Part B coverage, along with some extra benefits, for example, prophylactic mastectomy as discussed above. 

So, depending on the company, a Medicare Advantage plan may cover mastectomy at different percentages and may have different coverage requirements. It’s best to discuss the coverage with your insurance provider.

Medicare Part D 

Medicare Part D insurance is a separate plan for prescription drugs that may be needed after medical treatments. It can be added to your Original Medicare plans (Part A and/or B) as a separate plan, or, if you have Medicare Advantage, then you might already have Part D coverage included. Most insurance companies do this to provide an all-in-one package.

Whatever type you have, know that Medicare covers all medically-necessary drugs. For cancer, these include:

• Oral prescription drugs for chemotherapy
• Anti-nausea drugs
• Pain-killers and other drugs used for cancer treatment

It’s important to check your Medicare plan’s list of covered drugs and their costs. Depending on your plan (Part A, B, or C), the coverage percentage of cancer drugs may vary. This can affect your out-of-pocket costs. 

Supplemental Insurance

Supplement insurance is provided by private companies to help you cover out-of-pocket costs for Medicare. There are two popular types; Medigap and Medicaid. 

While Medigap is designed for regular and higher-income individuals, Medicaid helps low-income individuals pay deductibles, coinsurance, and co-payments for Original Medicare. However, if you aren’t enrolled in Part A or B, you can’t avail of supplemental insurance. 

This insurance won’t directly cover your mastectomy costs, but parts of it.

Article updated on January 12, 2024