• Medicare Coverage

    Asked by Kurious on Wednesday, April 17, 2019

    Medicare Coverage

    I know Medicare will cover costs for a cancerous breast mastectomy with reconstruction, but I don't know if they will cover cost of breast correction (for symmetrical purposes) of the other breast which has no cancer. Any medicare patients out there who have had both covered?

    5 Answers from the Community

    5 answers
    • BuckeyeShelby's Avatar

      Wrong info on the phone is why most insurance companies have disclaimer. "Benefits are an overview of coverage not a guarantee of pymt and may not be interpreted as a modification to the terms and conditions in the membership booklet." Yeah, that's the one our company uses... And people are human and give wrong info. Some of y'all know that I audit customer service phone calls for my company, so yeah, there is wrong info. Not major scads of it, but more than I'd like. But if it came down to it, our calls are ALL recorded, so it can be proven what a rep did or didn't say.

      That being said, good luck, Kurious. My own cancer is farther south, so no breast reconstructions needed for me. I hope you find your answer.

      about 1 year ago
    • ChicagoSandy's Avatar

      It is current Federal law that surgery &/or reconstruction of the opposite breast to achieve symmetry MUST be covered by Medicare and ACA-compliant private or employer plans (which is to say darn near all of them). Most Medicare Part B supplements pick up the co-pay. And per my lymphedema specialist, here's what else must be covered--for both mastectomy and lumpectomy patients, as by Federal law a lumpectomy is considered a "partial mastectomy:" One prosthesis per affected breast every two years, and two "mastectomy bras" (i.e., containing a pocket) per year. (Nope--you can't apply for reimbursement for regular bras unless they have pockets for prostheses--those slender pockets in Coobie and Genie bras containing removable pads don't count).

      But what ISN'T covered by Medicare (and is optional for other insurance)? Lymphedema compression wear--sleeves, gloves, gauntlets, donning/doffing aids, wraps, pumps (though some creative doctors find workarounds for the latter, such as coding them for prevention or treatment of DVTs rather than LE). And some compression stockings are covered--again, not for LE but for vein health & safety.

      Why isn't lymphedema treatment wear covered? Because the regulations were written in consultation with physicians; and the average doctor (even breast cancer surgeons) receives no more than 30 minutes of instruction about the lymphatic system (and even less about what could go wrong with it) in medical school. There are even breast cancer surgeons who don't really know about it (my BFF's, when asked about alternatives to arms for blood pressure & needles after a bilateral mastectomy & sentinel node biopsy, scoffed and said "They treat lymphedema with compression sleeves, so why wouldn't a blood pressure cuff be safe?"

      about 1 year ago
    • Kurious' Avatar

      ChicagoSandy- Wow, that was allot of info. I know Medicare will cover for silcone implant, but I'm not interested in any type of prosthesis. If I'm going to need a mastectomy followed by reconstruction, I want the reconstruction to be a DIEP lap procedure(using my own skin), and not some silicone implant that brings it's own set of problems. So far I've had no lymphedema problems, but the info you gave on it is helpful should I need to know in future. I guess my doctor will eventually let me know if the DIEP lap procedure is covered. If anyone has had that procedure, I'd like to hear from them. Maybe I should put that in a seperate question. Thank you for responding.

      about 1 year ago

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