Treatment for breast cancer is often covered by Original Medicare, as it is with other treatments for cancer. But not all types of treatment are considered medically necessary. But what category does breast prosthesis fall into?
If this is a treatment that has been recommended to you and you are considering, you probably want to know “does Medicare cover breast prostheses?” Below you’ll find a straightforward answer to the question so you know what to expect. You will also find the average costs of breast prosthesis if you have to pay out of pocket.
Does Medicare Cover Breast Prostheses?
The short answer is yes. Medicare will cover the cost of breast prosthesis. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your breast prosthesis. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for breast prosthesis. Parts A and B provide coverage for some breast cancer treatments, but not all of them. Among those Original Medicare covers include breast prosthesis.
Original Medicare provides coverage for your breast prosthesis if it is considered medically necessary. The operation must also be first ordered by your healthcare provider for Original Medicare to provide coverage.
Coverage for breast prosthesis is provided by Medicare Part A if your breast prosthesis takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
On the other hand, coverage for breast prosthesis is usually provided by Medicare Part B as it often takes place in an outpatient setting. Once approved, Medicare Part B covers 80 percent of the costs of breast prosthesis. You will pay for the remaining 20 percent.
Part C Coverage for Breast Prosthesis
Medicare Advantage plans (Medicare Part C) also provide coverage for breast prosthesis. They cover everything Original Medicare covers, as well as some additional benefits. However, exactly what it covers and your out-of-pocket costs will vary depending on the specifics of your plan.
Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider will prescribe to you.
Medicare Part D plans provide coverage for medications that you need for your breast cancer treatment such as chemotherapy medications. Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.
How Much Does Breast Prosthesis Cost?
The cost of a breast prosthesis can start as low as $15 but can reach to over $500 for one breast. For someone who had a double mastectomy, the costs will double, starting around $30 and going to over $1,000 for a pair.
A major factor in the cost is the material the prothesis is made from. The least expensive options are usually foam prosthesis. A middle level option will be of silicone. The most expensive prostheses are the adhesive ones or “contact” prosthesis that sticks directly to the skin.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare cover toenail fungus treatment?